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0 • <br />qq r <br />Cr' <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 part)(to be'billed for additional PHS-EHD stats time expenaea oeyunu cne o nuui mim muni iiiaLaLL— wji <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing Address �_ISDL)-Fh �laC�� 14P1ts <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev 13/95, UST <br />May 5, 1994) <br />2 <br />Date 7 1Z(,/0& <br />EPA SITE # _ S <br />PROJECT CONTACT & TELEPHONE # M1 <br />_ T O <br />F <br />FACILITY NAMERam Lane .� <br />PHONE # <br />A <br />C <br />ADDRESS :3 ?.J <br />I <br />L <br />CROSS STREET i <br />1 <br />I <br />T <br />Y <br />OWNER/OPERATOR -...� <br />Sero lC S;it4wm ?(6 ver les <br />PHONE # <br />PHONE # <br />C <br />CONTRACTOR NAME <br />(7 r, <br />0 <br />N <br />CONTRACTOR ADDRESS `� <br />✓` <br />CA LIC # <br />CLASS C 6l <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED YES_ NO <br />WORK.COMP.# 3 <br />A <br />C <br />FIRE DISTRICT C1 <br />PERMIT # <br />�1 <br />T <br />0 <br />BOARD OF EQUALIZATION /# <br />R <br />TANK ID # TANK SIZE CHEMICALS TO <br />BE STORED PROPOSED INSTALLATION <br />DATE <br />39- <br />-� ]0�0 <br />T <br />39- — I C1. t2T0® °;1ta) Qf1 <br />Q—I-2tbO <br />A <br />39- <br />N <br />39 c — �i��() �r2� DIS ►P�c�=.�-��OU <br />K <br />39- <br />39- <br />39 - <br />P <br />II <br />PPROVE WITH CONDITION S) <br />DISAPPROVED <br />L <br />A <br />_"APPROVED <br />(SEE TACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />DATE <br />APPLICANT <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />� <br />DATE/ 160 <br />APPLICANT'S SIGNATURE: TITLE <br />1 <br />Indicate the responsible part)(to be'billed for additional PHS-EHD stats time expenaea oeyunu cne o nuui mim muni iiiaLaLL— wji <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing Address �_ISDL)-Fh �laC�� 14P1ts <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev 13/95, UST <br />May 5, 1994) <br />2 <br />Date 7 1Z(,/0& <br />