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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO AHS-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 PHS-END UPON RECEIPT;OF THIS'GETTER.... ._.. <br /> = DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # ' PROJECT CONTACT b TELEPHONE #J 1 e7 <br /> 6,1 <br /> F FACILITY NAME 1 � � PHONE # r <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> YOWNER/OPERATOR ® ® PHONE # <br /> C CONTRACTOR NAME o lt4o , PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS ICA LIC # fi CLASS � ® <br /> T <br /> R HAZARDOUS. WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT -e tr I PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIIIIIIIIITANK IIDI#11111111111 TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39• 1 [) L3 1 f TE <br /> T 39• i - U l wd <br /> A 39• -IA7 VN ,. <br /> H 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IltlffflTl' T <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ..__ (SEE ATTACHMENT WITH CONDITIONS) —' <br /> N PLAN REVIEWERS HAKE DATE <br /> tllltlltlllltlll11111111111111111111111If 111111111111111111111[]Tffffl=llllll 111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLdC HEALTH SERVICES. OWNER OR LICENSED AGENTIS 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 TOE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI " <br /> APPLICANT'S SIGNATUR TITLE !> DATE <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the S hour minimum installation <br /> payment. The party must acknowtedge this responsibi.tity for the additional billing by signature and date beton. <br /> Mailing Address f R__ <br /> Day Phone Number <br /> Signature Date <br /> EH 23 0 /13/ 5, UST Reg• May S, 199 <br /> 4 <br />