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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 <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: kA1 C W A,E L ILII A L p r( CONTACT PHONE # <br /> id3-HS'z <br /> FACILITY NAME: 9 9 5 µE c FACILITY PHONE# <br /> Zoe — 9s� - S39Q <br /> FACILITY ADDRESS: -4 �a o CROSS STREET: <br /> �Lt on,rZ �� cr <br /> OWNER/OPERATOR: PHONE: <br /> QACAS' l � L-LF}A ,4 Arc(,t,f� Zo <br /> CONTRACTOR NAME: PHONE: <br /> A c.-r �I E�(<.�niE.E2r�cr 16 - -3 3- //rL <br /> CONTRACTOR ADDRESS: P-0 , B cX (021— CA LICENSE# <br /> W- SA-cry CA SS-69k �p / "} Zig <br /> HAZARDOUS WASTE CERTIFICATE: ES NO WORKERS COMP# <br /> FIRE DISTRICT: S--o C 1/_ro,4 C 1 ?-Y PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 19-, 00 o A.S0c«L(L- - Fr 4 <br /> $ 00 0 C. 4510 L1"LR_ <br /> 0 o o 1E4K t <br /> ❑ APPROVED PPROVED WITH CONDITION DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE '1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WI SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT.OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED.,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OFE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COM ENSATI LAWS OF CALIFOIA." <br /> APPLICANT'S SIGNATURE <br /> TITLE C 0,j-�Z A-f_ o L DATE cR- O <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour <br /> minimum installation payment. The party must acknowledge this responsibility for the additional billing <br /> by signature and date below. <br /> Name- ( j <br /> Al A- y- Q_ 4 F c � t a.icy 2,Kr , T;,r . Date �l�c rrLc f <br /> Mailing Address .0 0 K to z s S A4.,Tv C A- 9 r6 9 1 <br /> Signature Daytime Phone 14 -3},� - 1 r <br /> C. REQUIRED SUBMITTALS -^ <br /> - 3 - <br />