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Ir <br />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 />Indicate the responsible partyto be'billed for additional PHs-EHu staTT rime expenoeu oeyunu uie o �jwul 111111111u." <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing Address d 1 &0,,4 �1c{ +6n 4 <br />Day Phone Number <br />Signature - <br />EH 23 008 (Rev 13/95, UST Reg' May 5, <br />994) <br />4 <br />Date -71-2-(,-,10C-) <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # An ^Lan <br />7 39 <br />/ _ <br />(� <br />r, <br />F <br />FACILITY NAME <br />-� elo f <br />PHONE # <br />A <br />C <br />ADDRESS :3304 jk <br />damwE <br />Lane-, Six A*m CA <br />I <br />L <br />CROSS STREET f <br />I <br />T <br />OWNER/OPERATOR <br />S�Ef�"l(>n <br />PHONE # <br />ii f� <br />lfS � 1 "Sri —21W <br />Y <br />,S(Firl,iC <br />t�© i --c <br />' PHONE # _l <br />8_ 36 U <br />C <br />CONTRACTOR NAME tiller <br />Q <br />U <br />0 <br />N <br />CONTRACTOR ADDRESS 2 <br />3 <br />] <br />CA LIC # CLASS 6l <br />` <br />TWORK, <br />R <br />HAZARDOUS WASTE CERTIFIED <br />YES NO_ MP.# W 3 Z <br />A <br />C <br />FIRE DISTRICT Cl <br />I XRM I T # <br />T <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />!ANK'!D' # <br />E LS TO BE STORED PROPOSED INSTALLATION <br />-V <br />r9- <br />A DATE <br />T <br />( 39- 4b, <br />n el -1-2 oe0 <br />i S S a <br />N <br />_jams <br />39 C{ "Min <br />-1-2000 <br />39- <br />39- <br />39-� <br />ffrnTuflTunflTurnnuffm I I I I I I I <br />P <br />L <br />APPROV APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />EE AT HMENT WITH CONDITIONS) C (JJ� <br />N <br />PLAN REVIEWERS NAME <br />Zf DATE <br />APPLICANT <br />MUST PERFORM ALL WORK IN AC <br />RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND EGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SE ICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK <br />FOR W CH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />TO WORKER'S COMPENSATIO LAWS <br />OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFOR NCE OF <br />THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF0 <br />IA." <br />APPLICANT'S SIGNATURE: <br />f <br />TITLE '� DATE/7a A90 <br />Indicate the responsible partyto be'billed for additional PHs-EHu staTT rime expenoeu oeyunu uie o �jwul 111111111u." <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing Address d 1 &0,,4 �1c{ +6n 4 <br />Day Phone Number <br />Signature - <br />EH 23 008 (Rev 13/95, UST Reg' May 5, <br />994) <br />4 <br />Date -71-2-(,-,10C-) <br />