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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 PHS-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-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # PROJECT CONTACT & TELEPHONE # M(KE L{ -G7 916 - 33.5 - (168 <br />F FACILITY NAME jj� IS M(J1 VVUlA j•« PHONE # ZO9-(o <br />C ADDRESS 330b WEST LANE 576CKT0A) GA �1526� <br />1 n <br />L CROSS STREET A G IiJE <br />T OWNER/OPERATOR` I PHONE # <br />Y JA V� VI/lc (LQ�4Z1 l F3�o�- <br />C CONTRACTOR NAME WAG7oi,) PHONE # -T( 6- 3.13 - I ( 6$ <br />0 <br />N CONTRACTOR ADDRESS T%p �x 107-5 �Ai �tC � qs(R� CA LIC # �II238 CLASS A B KAP <br />T <br />R HAZARDOUS WASTE CERTIFIED YES X_ NO WORK. COMP.#Wjj(T�065I�3j(o02 lZ• <br />A <br />C FIRE DISTRICT �vDcr-T� F((E DK -r PERMIT # <br />T <br />0 BOARD OF EEQUALIZATION # H 0, +9� — 0 V%o 2 -' <br />R <br />1111111111IANK 11111111111111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />1�0 a_0 a &IkL,LoN '� NL. f� 9+DATE <br />T6 Lo3g-- 5 o L o . UN i... 6FA D 471- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />1111 <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME �/A DATE `` <br />111111111111111111111111 I I I 1� Illlillll liiiillil l Ililllili111111111111111111111111111 1111111111111 <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 CALIFORNIA." <br />APPLICANT'S SIGNATUR : C TITLE O�.rlG�.0 DATE <br />Indicatethe responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this /r�essppon�s/ibility for the additional billing by signature and date below. <br />Name 5 rK C ( L <br />Mailing Address igc)s ivy v4 oajy ( S7i0Cg76N CA IS2©�O <br />Day Phone Number 2"'1l4Wz — 8 3 o lL <br />Signature Date <br />EM 23 00: - .. f <br />�/, ' <br />