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11-33-1996 2:56PM <br />FROM <br />• <br />C <br />P. 4 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FQR INiirALLATIOk OF uWERGAWND STORAGE TANKS IS ONLY VALID FUR THE CALENDAR Y A IN :tHICX IT HAS BEER ISoJED. <br />i PERMIT MAY 86 EXTENDED INTO THE NEXT CALENDAR YE31R IF A LETTER IS SENT TO PFtS-EHD RS4UE^s7IkG THIS e�C7ENSIQN THIRTY DAYS <br />PRIOR TO THE END OF TAE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION 14AY SE OWTM SY PHS- HO UPON RECEIPT OF THIS LETTER, <br />00 NOT WRITE tN ANY SHADED AREAS. <br />VA SITE N �� T aRolEcr CONTACT & TELEPHM <br />F f FACILITY NMiw <br />f <br />j � ADDRESS 2 <br />iI L CROSS STRE$? <br />T OWNER/OPERATOR PHONE N <br />C ! CONTRACTOR NAME 1 PHONE 4 <br />N CONTRACTOR ADDRESSrD?�04:j, �� �. l(� CA 2\L��� CLASS <br />R NAZARoaA WASTE cz-VIFIED YES NO E wY1RC.C:dTiF.N ` ` Q1 <br />A <br />C I EIRE DISTRICT PERHIT <br />D I BOARD OF EQUALI.?ATIO9 M I <br />39 - <br />lit <br />TANK SIZE PICA" To BE : <br />\Zi. / <br />PIROPCM I RSTALLAT I OV <br />–DA'E <br />AP <br />V APPROVE WITH CONDITION(S) DISAPPROVED <br />ATTAC NT VIIH CCAIDITIMS) �^ <br />N PLAN REVIEWERS NAME WAX 1^–/ DATE � ��i —V <br />MUM I III1111ri ffl-IT , II ,�iII III III I <br />ff <br />APPLICANT MUST PERFORM ALL '.tQatK IN AGGORDANC! WITH IAN JOAWIN COUNTY ORDINANCES, STATE LAws, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUS0 C I!AtTH SWIMS_ OWNER CA ICZN3F.Q ADEM °S SIGNATURE CERTIFIES TRE FOLLGWING: "I CERTIF" THAT IN <br />THE PBRFORMANC! OF THE WORK FOR WHICH THIS PERMIT iS 153M, I SHALL NCT EMPLGY ANY PERSON IN SL�H A MWNER AS TO BECOME <br />SI:El1ECT TO WORY,CR'S ENSATION LAMS OF CALIFORNIA CONTRACTOR'S HIRING OR StI�NTRACTING SIGWATtM CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THL RFORMANCE OF THF WCRK FOR HICH THIS PERMIT IS ISSUED, I SHALL E4PLOY PERS{NS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF :A 1'ORNIA." <br />I <br />; <br />? APPLICANT'S SIGNArUR TITLE DATE \2=\b <br />Indlcate the responsible PartY Ito be biLted for qb <br />payment. The party must ackmwt this rearomi <br />tRsme <br />Malting 4bdre5s,.­ )-- <br />lay ;:hone Member \\Q ;�. �^ <br />Si <br />EH 23 008 (Rty 12/13/95, UkT Reg°s May 5, 3994) <br />t PNS-EHD staff Lime excerded beyond th+ 8 hear mirim m installation <br />for the adaltionat bitting bV signavurg and Cate below. <br />4 <br />Datq �2\3�°l� <br />