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. ,.,e . <br />P r 0 <br />1 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 BEEW ISSUED. <br />A PERMIT MAY BE EXTENDED INTO THE NEXT CAL..-YDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTNSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A 34E YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UP09 RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE #cA '� 9e <br />_- C� L. _ PROJECT CONTACT 8 TELEPHONE # V Iti� ) LL SILT R 33 --G`5778 <br />F FACILITY NAME eL�, l �(� �' _ �1 PH E #11- � l _ t� <br />C ADDRESS `25-7!5 CC)UNyr CL _ <br />I <br />1 L CROSS STREET L 0v <br />I <br />QWNER/OPERATOR Q1 C 'u PH _ <br />�# <br />I 1 <br />I C CONTRACTOR NAME W v �N PHONE # {tel 28 <br />i N CONTRACTOR ADDRESS 51667 � COUP- LIC # 2�G CLASS <br />T G <br />R HAZARDOUS WASTE CERTIFIED YES%C- NO WORK.COMP.# (D 0 <br />A <br />C FIRE DISTRICT I QFPERMIT # <br />T <br />0 BOARD OF EQUALIZATION # H Y1 <br />)f � e, <br />R <br />T <br />A <br />N <br />K <br />IIIIIIIIIIII111111111111111111 <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />1111 <br />TA�IK <br />ID <br /># <br />- <br />_ <br />_ <br />_ <br />_ <br />_ <br />_ <br />R <br />P <br />TAXK SIZE 'V / I CHEMICALS TO BE <br />INSTALLATI <br />L _ AP 0 I APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEE ATT HMENT-WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />Illllllll��ii�iillli i ���� it I i »tiii� i�l lilliilill <br />APPLICANT MUST PERFORM ALL WORK IN AC DANE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERV S. 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 LAYS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE F THE '"K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA <br />." r [20� <br />APPLICANT'S SIGNATURE: TITLDATE <br />4;L— <br />Indicate the responsible party io be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing A <br />Day Phone <br />U <br />a <br />Signature�e}�/ lr _1,yc Date <br />EH 23 008 (Rev 1/7/92) WP {�-�, U� �1 D _ G t'il✓✓/�V' <br />