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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WICK IT NAS BEEN Injo. <br /> A PERMIT CAN HE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER ES BENT TO PUS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ON TINE EXTENSION MAY SE,GRANTED BY PNS-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN MY SHADED AREAS. <br /> EPA SITE t PROTECT CONTACT i TELEPHONES i262 -928-a/?6 <br /> F FACILITY NAME PNQN1E0 20 9 -9$a 73 8 8 <br /> A <br /> C ADDRESSD STi�r50:cI <br /> I <br /> L It I STREET �±/ Po r2 7" GCJ <br /> I <br /> T TOR PHONE IN <br /> T C441,c <br /> ® CONTRACTOR NAME CoA-35 7- PHONE 0s '"P37 <br /> N CONTRACTOR Jg <br /> T Ze <br /> �/N Y�tf.rylid2/A CA LIC 0 3 91 C <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO {NpWCOP-8 7-&JG // S <br /> A <br /> C FERE DISTRICT PENUT S <br /> T <br /> 0 BOARD OF EQUALIZATION <br /> R <br /> b <br /> illlti1111T1ANK 101 {{{11{Illli TANK SIZE CHEMICALS TO HE STORM PROPOSED INSTALLATION <br /> 49 o®C-) E T FGJ 6"C_ DATE <br /> T 39- U coca Er'- v� c <br /> A 39- -7 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> Itll <br /> P <br /> L APPROVED APPROVED WITH CODITIOI(S) ®DISAPPROVED <br /> A YITN CONDITIONS) <br /> N PLAN REVIEWERS NATE DATE <br /> Ilttlttllttl{Illtill 11111 <br /> APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE YITN SAN JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND RE" ATIONS OF <br /> SAN JOAQUIN CUM PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TUEFOLLOWING: 01 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SNALL NOT EMPLOY ANY PERON IN SUCH A NAJM AS TO BECOME <br /> SUBJECT TO 'S COMPENSATION LAYS OF CALIFORNIA." CONTRACTOR'S NIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> eI C UTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS KNIT IS IMAM, I NIALL OPLOY PUBN@ KWW TO mXU=#8 <br /> COMPENSATION LAYS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: -1 � TITLE J JB DATE -22-9'z <br /> EN 23 000 (Rev 1/7/92) WP Pepe 3 <br /> e elv- <br /> eml <br /> 3 <br /> S` <br />