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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 # I✓G u e <br /> F FACILITY NAME U e-it- pz PHONE # 2v9 - 23 - _� <br /> A nn� <br /> C ADDRESS J S• 1'l a w S <br /> L CROSS STREET Q� mor <br /> T OWNER/OPERATOR n ]� PHONE # ^� q <br /> Sys -� �Z <br /> Y S L} Z <br /> C CONTRACTOR NAME r PHONE # <br /> 0 11' CQ -951 <br /> N CONTRACTOR ADDRESS 6, S� A e Q-3 FCA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES Xe NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICTPERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- <br /> DATE <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A #EE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE 9 <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." (/ <br /> APPLICANT'S SIGNATURE: /� ,— �f TITLE V � • DATE 1SIM <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 /> Name 8j)4eo- P¢�ru�ty 1 <br /> —T J1 n D11p < C�2 /b <br /> Mailing Address Py � �� 1 JA - <br /> (. .�9J <br /> Day Phone Number (ZQ <br /> Signature �IIY-� ___ Date //Iof�V <br /> EH 23 008 (Rev 12/13/95, UST Ref's May 5, 1994) <br />