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SAN IN COUNTY PUBLIC HEALTH S <br />ENVIRONMENTAL HEALTH DIVISIO <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 />FDA SIT_ ®O/4 03 ® G� g ) PROJECT CONTACT 8 TELEPHONE *` aa 9 — 5 61 <br />1 L <br />F FACILITY NAME PHONE <br />A <br />C ADDRESS <br />1 <br />L CROSS STREET <br />T OWNER/OPERATORijI f1 , /� - PHONE <br />Y I 1 A_AY.L6 -i®s- 9,q; -poi/ %Jo9-y7 7- <br />C i CONTRACTOR NAME PHONE R D o <br />C <br />N CONTRACTOR ADDRESS ') • CA LIC b O ® CLASS <br />R HAZARDOUS WAST: CERTIFIED ES NO WORK.COMP.n QZ�-,009 -7—, 8- <br />A o� ` O <br />FIRE DISTRICT PERMIT <br />0 ' BOARD OF EQUALIZATION t jfLj — ®41(,/ <br />R r 11 a <br />I I <br />IlIIIIIII Illtlllitttllttitlllt <br />TANK ID <br />TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTAL'-ATION <br />39- <br />I <br />i DATE <br />- 39- <br />9 -39- <br />39- <br />N 39- <br />N <br />K 39- <br />39- <br />39- <br />Itll {tltlltitttttlttltlltffltl t{tlltl[t[Ilt{IIt[It{II!!t{Itfllttttltltltlltlltll[tllllt[lllllltllll{tiClttltttttlftltt{itltt <br />IP <br />I L <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />i A <br />_� <br />( - CHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME <br />` DATE Z <br />Illttttttllttt[!II{[III <br />unif I If III I 1111111111111111111[t[ <br />APPLICANT MUST PERFORM ALL WORK IN <br />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 <br />OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />pm I <br />_ TITLE �,/LC d�LR> DATE /O <br />i <br />Indicate the responsible party to be <br />billed for additional PHS-"EHD stat` time expended beyond the 8 hour minimum installation <br />payment. The pa ty must acnowie4ge <br />this responsibility for the additional billing by signature and date below. <br />e <br />Name <br />DA 5 ' ® 7 <br />Mailing Address <br />/ — 77.....34 <br />Day Phone Number.T- <br />/4-) <br />Si XtureZ'/Date <br />_. <br />EH 23 008 (9ev 127t3795, US —1 Reg Is May 5, 1994) <br />UST SYSTEM DRAWING INFORMATION <br />