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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <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 />1rn STP�RMc� <br />CONTACT PHONE # <br />q - a c� J 389 <br />FACILITY NAME: <br />LAD I N&i,A09,1AL- OSP l rA L -SWR <br />FACILITY PHONE# <br />aoci - s s 4 - s/ -P � <br />FACILITY ADDRESS: <br />975 S • V�A+IzmoraT NL, I L001 , « gspw) <br />CROSS STREET: <br />OWNER/OPERATOR: <br />)-ODI I*-"R1RL IAOSP ITPiL <br />PHONE: <br />aoci -?)s4- <br />?)s4 -CONTRACTOR <br />CONTRACTOR NAME: <br />PsuLf- -J N . \1lJ ILSON <br />PHONE: <br />5 S - 56 7 - 6�2QE5 <br />CONTRACTOR ADDRESS: <br />6150 VAPA E-nl RP Y\QARo , �L L7eRgD6 CA g50 <br />CA LICENSE # <br />/-% 4%q 599 14 A 7-, <br />HAZARDOUS WASTE CERTIFICATE: / <br />✓ YES NOXEMP <br />WORKERS COMP # <br />T' <br />FIRE DISTRICT: PERMIT # <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br />(,00 - 4 67w- 4 1/z' 0D 3T/Z-,L V <br />0004- <br />10004- <br />0 <br />❑ APPROVED ❑ APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE 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 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." _ <br />Applicant's Signature <br />Title (19 riv ti ter' <br />Date S/ 12' / 4 <br />Indicate the responsible party to be billed for additional 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 ks►!t.F-y q4%L.S00 <br />Date <br />Mailing Address (v 150 4KE Q QPr11C V� Ro p� D L ©� IA DG , G Ik 956 23 <br />Signature l' Daytime Phone 530 56'7 - (69Q0 <br />Revised 8/3/07 <br />