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41 <br />SAN JO.AQUIN COUNTY PUBLIC HEALTH SERVI <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TMK INSTALLA IGI� <br />THE APKICATION POR cN$rALLATtON OF 4NFiRMUNO STORAGS TAUS IS QNLY VALID FIR THE CALEMM YEAR IN WICH `TL$t N ES J:D. <br />A PERMIT MAY BE EXTEmogo INTO tH NEXT CALENDAR YEAR 1P A LETTER IS SENT TO Pks-END R£A=10 <br />aTIMG �Q TY DAYS <br />PRIOR TO 114 imO OF THE CALENDAR YEAR. A ONE T'%E, ONE YEAR EXT1ENBIOd MAY SE GRANTM SY 1 � aNF5 LETTER, <br />EPA SITE N <br />A11 FACILITY NAME <br />ADDRESS <br />L CROSS STREET <br />T OWNER/OPERATOR <br />C CONTRACTOR NAME <br />N ; CONTRACTOR ADDRESS U < }"U <br />1() <br />T <br />i R ! NAZARDCUS WASTE CERTIFIED <br />YE <br />i = <br />'� <br />T <br />! FIRE DISTRICT I�G.R, <br />��1 <br />0 <br />! SOARD OF EQUALIZATION 3 <br />R <br />00 NOT 'WRITE tN AV SHADED AREAS. <br />PROJECT CCONYACT $ TELU9ONE 7_T_%,c <br />\&Oe. <br />SCA LIC <br />3CLASS <br />PERMIT - !� <br />iiliiillilllAlNll��lilllll�llli� ' <br />I( # TANK SIZE CHEAfICALS TO SE =RED PROPOSED INSTALLATIOI <br />S9- QX7x - - DATE <br />T 30- v11T sA <br />4 39- <br />N 89- <br />K 39- i <br />34- _ <br />I i!iffffumm 1111111nn ills If 111111 fill it I rm=111111111I1I11117 <br />P <br />L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br />A(SEE A'fTACNNEN'I wIlm CGNDITIms) <br />N PLAN REVIEWERS NAME OATS <br />dldillitll111Iitiilid�! ! ldddl !lift ti! i t i t il$111 i ii iii i ! ddd 1 <br />APPLICANT MUST MFORH ALL WORK IN NCE WITH SAN 40ACUIN OVjNTY MINAMCES, STATE LAws, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC REAuTH SERVICES: 06N@.4 OR LICENSED A4EAIT'3 SIGNATME =T1ftES THE FOLLOWING: "I CERTIF" THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i $HALL NOT 9VLGT ANY PERSON IN SUCH A MANNER AS TO SES+ON$ <br />SUBJECT TO W10AKER'S COA NSATIOH LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUMMUTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I wERTIFY THAT IN THE rfRFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WRKER'S <br />ZmPENSATION LASTS OF CA PORNIA." <br />APPLICANT'S SI <br />Indicate the re°sponsibte party Iko be bitted for <br />payment. The party must acknowledge khts re <br />Mai L i n9 <br />TITLE Qui DATE \L� <br />1% at PHS-EHD staff time eXZerded beyarid the S hour mirfum instal tat -on <br />for tie adcitianat bitting by signature and date below. <br />lay ?hone Number \\_Q <br />Si gnacure <br />EH Zr 008 (MeV 12/13/95, T Reg's Noy 5, 1994) <br />Oates\ -\ 7 1 q e® <br />