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PP".. <br />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 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />I r <br />EPA SITE » <br />FI L I TY NAM wx x Opt -T-[ <br />A <br />ADDRESS <br />1 2 <br />I <br />J L CROSS STREET <br />I <br />T OWNER/OPERATOR <br />PROJECT CONTACT & TELEPHONE if <br />,I C <br />0 C RACTOR NAME 1 , JA4 <br />/ 11� <br />N NIBacTOEss <br />R HAZARDOUS WASTE CERTIFIED YES No <br />— <br />A <br />C FIRE DISTRICT <br />I T <br />0 BOARD OF EQUALIZATION <br />R <br />111111111 <br />TANK ID » <br />39- Cc I <br />T 39- rl �- <br />A 39- _ <br />4 39- —' <br />K 39- <br />39- <br />39- <br />- P 1111 TTff <br />-L APP <br />A <br />-N PLAN REVIEWERS NAME <br />- 1111111111111111111111 11 111111 1 <br />APPLICANT MUST PERFORM ALL WORK IN AC <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERV <br />THE PERFORMANCE OF THE WORK FOR WHICH <br />SUBJECT TO WORKER'S COMPENSATION LAW <br />"I CERTIFY THAT IN THE P�fANCE F <br />COMPENSATION LAWS OF CA IFORNIfORNIA." <br />APPLICANT'S SIGNATURE: <br />TANK SIZE <br />A <br />I (q IA <br />CA LIC <br />PHONE 0 <br />PHONE x <br />PHONE A <br />CLASS rt_ F <br />WORK. CCMP.;t <br />PERMIT » <br />TO BE STORED - <br />INSTALLATION <br />.moi- L1N (e-ikC�.J� nerE <br />;DYED APPROVED WITH CONDITIONS) DISAPPROVED <br />E ATTACHMENT WITH CONDITIONS) DATE <br />I 1111 til 1 1 111 I11l1 1 I lllllill 1 I� 1 1 11 11111111 !! <br />OR NCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS Of <br />S. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />HIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />THE ;�C," WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />'a- <br />arcate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />e party must acknowledge ,this responsibility for the additional billing by signature and date below. <br />i ling Address E73-1 lL--tt—L "cl� 5;4-gf6f: &kms �_� [��`q, <br />y Phone Number ��(p j" <br />gnature Date <br />F 23 008 (Rev 1/7/92) WP <br />