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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE #5-+-ve <br /> FF FACILITY NAME S� Vnt ll�� �C�o\ 1 ( — r OI4�IU CLT-d PHONE # 3 25 lq <br /> ADDRESS <br /> I I tl I T)m v Seo iD <br /> L CROSS STREET VCnU C <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y S-to&ialv rid - 6 <br /> C CONTRACTOR NAMEta tin PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS 1 Q jCA LIC # Q CLASS <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO WORK.COMP.# <br /> A IL I) _y S <br /> C FIRE DISTRICT A oc o f\ PERMIT # <br /> T /0 0 <br /> 0 BOARD OF EQUALIZATIO # _o <br /> 'V 1 <br /> R I 4 oS� <br /> TANK ID # TANK SIZE CHEMICALSTOBE/STORED PROPOSED INSTALLATION <br /> 39 3 �.���� 1)01 Up.Ce�fri( 161,11 DATE <br /> T 39- �n,M6 <br /> A 39-- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A 4SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ��i y�j��l/ DATE �S <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." t .1 <br /> W _ <br /> APPLICANT'S SIGNATURE: _ TITLE _ ATE _ I <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the_additional billing by signature and date below. <br /> Dnrn� 4 �V1Gln eCll�� <br /> Mailing Address <br /> Day Phone Number ( U I -S71 6�16 Fit, <br /> Signature _ Date_ �� <br /> EH 23 008 (Rev A 3/95, UST Reg's May 5, 1994) <br /> CA,-(_ <br />