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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-END 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 /> EPA SITE # PROJECT CONTACT 8 TELEPHONE #—�-- l - <br /> F FACILITY NAME - PHONE # <br /> A <br /> C ADDRESS — ` �� <br /> I <br /> L CROSS STREET <br /> I <br /> T I OWNER/OPERATOR <br /> y C� �R��V�- LO M 1��.R� PHONE # <br /> Y ; c�U\1�1 �. Z L 1.1 � S rJ - i U <br /> C CONTRACTOR NAME .� PHONE # - G�A , <br /> 0 <br /> N CONTRACTOR ADDRESS -1 ,, c CA LIC # CLAS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES _ NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT ; c- _0 —D _ ` - PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK <br /> II1111111IIIIIIIIIIIIIIII <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- l r) I!L DATE <br /> T 39- <br /> A 39- I �` <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39- <br /> P <br /> L APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED i <br /> A ` 'A` DATE(SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME A/ hn <br /> 111111111111111111111 1111111111111111 111111111111MIMMI11111 �� Iiilltl <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 061 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE• TITLE 6;L7 DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name—T' 1 �j A C.�. 1 Pti\\ /� S C.0 L\ P.\ t; — <br /> Mailing AddressZ�r5(� 5�1�11Z� S L, L-�)� `� L�� nLz <br /> Day Phone NumberL��� <br /> Signature Date <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />