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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 3E EXTENDED INTO THE NEXT CALENDAR YEAR IF A LEITER IS SENT TO PHS-EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRICR TO THE ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY SE GRANTED 3Y ?HS-EHO UPON RECEIPT OF THIS LETTER. <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> ERA SITE # PROJECT CONTACT $ TELEPHONE16q <br /> FACILITY NAMEQ IGF--- /"I I PHONE x. y <br /> ADDRESS <br /> b " <br /> CROSS STREET <br /> I OWNE PERATOR f PHO;;_`, <br /> 1 CONTRACTOR NAME o PHONE <br /> CONTRACTOR AODRESSte®glf <br /> CA LIC /oe4 l CLASS <br /> HAZARDOUS '.TASTE CERTIFIED YES NO ' WCRK.CCMP.; <br /> :IRE OISTRICT <br /> Gtr,�-�rra�=�► tzt�;E- -da,�c�Cn�icA�C"" <br /> ; 30ARD OF ECUALIZATION <br /> I <br /> 11111111111E t111111111t11 <br /> TAANKNK ID 4 TANK S ZE CHEMICALS i0 BE ST �� A pp PRCPOS'cD INSTALLATION; <br /> 39_ `u(.AW_ OATS <br /> 39- <br /> 39- { <br /> 39- <br /> 39- l ; <br /> 39- j 1 1TI11T <br /> llil <br /> APPROVED APPROVED WITH CCNOITICN(S) _ DISAPPROVED <br /> �= T CHMENT ITH CONDITIONS) <br /> ?LAN REVIEWERS NAME DATE <br /> 111111111111111111tltlllfltttllltllltl ! 1 lt1111111111 1111t111111111t1t! Iiltltiilllllllll l! 1 fllltlll1111 111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN :OAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSCN IN SUCH A MANNER AS TO 3ECCME <br /> SUBJECT TO WORKER'S COMPENSATION S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br />"I CERTIFY THAT IN THE PERF RMAN RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL cfPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF r LIFOR " ! <br /> i <br /> APPLICANT'S SIGNATURE TITLE� ^ DATE <br /> icate the responsible party to 'oe bitted for additional PHS-EHO staff time expended beyond the 8 hour minimus instalLation <br /> ent. The party rust acknowledge this responsibility for the additional biLLing by signature and date below. <br /> Ling ACCress � _ `"C GA `--1���t�c "o . �'�� 7 �.sC./✓ <br /> ?h umoer <br /> atu a Date <br /> (, ev 12/13/95, UST Reg's May 5, 1994) <br /> L <br />