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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # - d�� �� PROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAME PHONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET �N) -- _�� 7 N 7 F— <br /> I I <br /> TOWNER/OPERATO PHONE # <br /> Y `�. \Q -� n\,-\• `l0 <br /> C CONTRACTOR NAME PHONE # QCq <br /> 3 <br /> 0 p n <br /> N CONTRACTOR ADDRES �- CA LIC # �2 LP CLASS NAzB <br /> T 1u Q h <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# r�1' l l31 lZ / <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- Z `��2 DATE <br /> T 39- <br /> A 39- l C- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39-P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIII �) �� ����� �� ������������� �� 1111111 IIIIIIII <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 CALIIFFORNI�A." n/ <br /> APPLICANT'S SIGNATURE: // O �/ 1 ( t/ TITLE DATE V6 <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledg A�isres7ponsibiLity for the additional billing by signature and date below. <br /> Name <br /> Mailing Address 2 �- <br /> Day Phone Number /��S�r�• <br /> Signature , G l ' =�1 Date' <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />