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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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. A PERMIT <br /> MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE <br /> CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> Sl 1� /J 11�� �G y�� J� CONTACT PHONE#��, f X63 xl <br /> PROJECT CONTACT: Gt1/ %J /�! Z5 Z�C� <br /> FACILITY NAME: , ��� S FACILITY PHONE# <br /> FACILITY ADDRESS: ' ' S �' G CROSS STREET: s� <br /> OWNER/OPERATOR d J11�i�� PHONE: _ g <br /> 0 (} <br /> CONTRACTOR NAME: PHONE: zs-� -71 VAO <br /> CONTRACTOR ADDRESS:�3 /� CA / <br /> LICENSE# ZS6��,b CLASS: B � <br /> 3— <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> G'odo `mac/ 1 a'��� �s 7 03 <br /> 1 v0d Gi Zo,1S <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> (see attachment with conditions) <br /> PLAN REVIEWER'S NAME DATE___ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FO ICH THIS PER IT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA." //-- I` � <br /> APPLICANT'S SIGNATURE: rZ�� TITLE JIJ /h DATE <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation payment. <br /> CLIA -r0 444The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name_ /Ui1�Glif�J A&/!!!�'I <br /> Mailing Address �� � &gL/ � <br /> �65 l���1Gd'�B , ��� V5 <br /> Day Phone Nu 4r <br /> Signature Fate_ <br /> EH 23 008 (Rev 3/15/02) <br /> 4 <br />