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N ' "ENVIRONMENTAL HEALTH DEPARTMENT <br />ENVIRONMENT HEALTH SAN JOAQUIN COUNTY <br />PERMIT/SERVICES <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 <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO 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 EHD UPON RECEIPT OF THIS LETTER. <br />PROJECT CONTACT: <br />1)ave- 40 E' Ir, <br />CONTACT PHONE # <br />612.5, 245• te2,06 <br />FACILITY NAME: <br />Iod i Writ o d CL N R i4 -fu <br />FACILITY PHONE# <br />FACILITY ADDRESS: <br />15� (Sba+n Fatanon+ A� r.Vc t" <br />CROSS STREET: I - <br />W \i1h� S4rEe-+ <br />OWNER/OPERATOR: <br />a� <br />PHONE: <br />q 2 -L4 -5X05 <br />CONTRACTOR NAME: <br />WeS-Eern 'Pj L n , 1 n c - <br />PHONE: <br />Cc r c1 "7 -T <br />CONTRACTOR ADDRESS: <br />If) -35F 8T San Diego CP g2i0 Z- <br />CA LICENSE # <br />U7.39E73 <br />HAZARDOUS WASTE CERTIFICATE: <br />YES NO <br />WORKERS COMP # <br />'L2-�t�I�So�S'I d -7I <br />FIRE DISTRICT: PERMIT # <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br />10,600 <br />❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />I <br />PLAN REVIEWER'S NAME �''1 p , DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN GUUN I Y ORDINANCES, ST A ATE LAWS, RULES AND <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br />FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br />ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE <br />OF THE WORK FOR WHICH THIS PERMIT IS ISS ED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." i <br />Applicant's Signature ` PER= <br />r ll <br />Title -eC I (Y1 � () i• S jT Date 11 11 -2 -IC -)—i <br />Indicate the 4ponsible party to be billed for additional EHD staff time expended beyond the 8 -hour minimum installation <br />payment. The party must ack <br />nowledge this responsibility for the additional billing by signature and date below. <br />Nameyi�-wri I n G ` Date III 4-� C)—) <br />Mailing.Address.3 23 L F S� San D 1-1 O CP <br />Daytime Phone k jCI ` 5 -7 Z ' 11-1-7 <br />Revised 8/3/07 <br />