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• SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <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. A PERMIT MAY <br />BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR <br />YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />PROJECT CONTACT: � ��.} ��.p� �ti1 ��- <br />CONTACT PHONE _ X52-- ,J3 <br />NAME: ��i/4�. <br />P/);eV/�L70,P <br />FACILITY PHONE# �Z33 70FACILITY <br />CROSS STREET: / <br />�'' <br />FACILITY ADDRESS: 1012 �✓ �� n��� �,,,�� <br />+ c/ <br />OWNER/OPERATOR/tt'W,eiUD HA,*tOF IvAeL,L <br />PHONE: 3 37J <br />CONTRACTOR NAME: <br />M (l f� ep� Ca. v AJC- <br />PHONE: 9l� 9�4_ S 37 <br />NTRACTOR ADDRESS. <br />Cye,Q) Z8 k L q-6-7 3- 0 <br />CA LICENSE # 8 CLASS: f� <br />3 <br />HAZARDOUS WASTE CERTIFICATE: NYES RNO <br />WORKERS COMP # <br />FIRE DISTRICT:C,t D <br />PERMIT# <br />BOARD OF EQUALIZATIO # <br />TANK ID# <br />TANK SIZE <br />CHEMICALS TO BE STORED <br />PROPOSED INSTALL DATE <br />,.[ <br />vow <br />1� l PrS�� <br />PROVED WITH CON DITION�DISAPPROVED <br />nAPPROVED <br />(see attachment with conditions) <br />` DATE O 02 <br />PLAN REVIEWER'S NAME <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN <br />COUNTY ENVIRONMENTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE <br />OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br />LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE <br />WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMP O PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLEDATE F O z <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name i✓I �1�2 /3 t�� z_-6// <br />Mailing Address <br />U) <br />Day Phone Number 'e)'� - 9SZ - 3 -7(-::, <br />r � <br />Signature , Date_ <br />EH 23 008 (Rev 3/15/02) <br />