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r � <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 3E EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHO REQUESTING THIS EXTENSION THIRTY OATS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED 3Y PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT $ TELEPHONE d7 / - <br /> F FACILITY NAME f�N�lc -- !�PHONE x ., �G7 <br /> C I ADDRESS / �/ � �-�'T—O ' ' <br /> I <br /> L ( CROSS STREET r^' <br /> Y i NE PE.RATORPHONE <br /> LL <br /> �7 I <br /> C CONTRACTOR NAME PHONEZQ9"`Lf -fSJJ <br /> 0 <br /> N CONTRACTOR AODRE5Sgo8 /o - <br /> r CA LIC ;*327,q 110I CLASS! 0F0z- <br /> ' T I <br /> R i HAZARDOUS 'WASTE CERTIFIED YES NO ! WORK.COMP <br /> A <br /> TI =IRE OISTRICT�T�c�, -� �- � ^�� PERMIT <br /> 0 30ARD OF EEQUALIZATION <br /> R <br /> 1111i111111l11111111111l1l1111 TANK SIZE CIT LS TO aE ST I PROPOSED INSTALLATION] <br /> TANK ID � �i'�r � �p <br /> 39- GiL9f� I f� W(.AK— GATE i <br /> T 39- i <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- t <br /> � 39- <br /> IP <br /> L _ APPROVED �C APPROVED WITH CONOITICN(S) _ OISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME OATE <br /> 11111IIHIII III IIIII <br /> 1 1 tlllllil !I1 t 1 1 Il1111 111111 111111111 t 11 it I11111lI11111i1 111 1111!1 1 1 111 <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 ?PLOY ANY PERSON IN SUCH A MANNER AS TO 3ECO4E <br /> SUBJECT TO WORKER'S COMPENSATION S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE :OLLOWINGIf <br /> "1 CERTIFY THAT IN THE PERF RMAN K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF LIFOR I <br /> " <br /> APPLICANT'S SIGNATURE TITLE�K�k'CT �Ir�1 /�7��rL DATE <br /> Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for ite additional ''billing by signature and date below. <br /> Name I`� <br /> mailing Adaressgrq _ I�CI'�W --C�"u—+� �`--, 7•��/"� <br /> Oay Ph umber ' 46,11 6113~ <br /> S g atu a ]ate <br /> EH ( ev 12/ 3/95, UST Reg's May i, 1994) <br />