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' � � • '`ikM � Nt� m� NT`` <br />pslyXI <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERV CES <br />ENVIRONMENTAL HEALTH DIVISION SEP 041996 <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br />THE APPLICATION FOR INSTALLATION Of N ENvfRONTMTEeNFTppA��//LIT-�EES �'1 <br />UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENCRE" YFI'iM'I�R 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 TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />,ixuicace the responsible party to be billed for additional PHS-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 />NameA47Ln ' i1i/�� k4,/2UClDf �S�o 14C 7-/S 2/IG <br />Mailing Address 1-.d. 1;bx f7' yJ F/2rmon7 CC( 9ys,3 �- <br />Day Phone Number <br />Signatu <br />EH 230 <br />s May 5, 1994) <br />1e-- <br />4 <br />Date <br />EPA SITE # C A �OC7 O <br />3 3 3 8 <br />PROJECT CONTACT & TELEPHONE # 9/e) 3 -?L 3 -//�8 <br />F <br />A <br />FACILITY NAME SO <br /># a d <br />PHONE # U 8 _7/y p <br />I <br />ADDRESS 93 C;?/ OV. <br />n C � ,;2 d <br />L <br />CROSS STREET <br />/ <br />1 <br />O a <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Yu/' <br />G S S .-7-%7 C <br />/S/O) 6.S <br />C <br />0 <br />CONTRACTOR NAME <br />121 n n C <br />PHONE # q s g <br />N <br />CONTRACTOR ADDRESS P 0 6®X <br />a -/S <br />CA LIC #_,aa <br />CLASS <br />T <br />VG C 6 <br />� 2L Met <br />R <br />HAZARDOUS WASTE CERTIFIED <br />YESLX NO <br />WORK.COMP.#A%GUG ' <br />A <br />-- 00 <br />C <br />FIRE DISTRICT C/41 &F <br />S F <br />PERMIT # <br />T <br />C — V a <br />0 <br />BOARD OF EQUALIZATION# -7- <br />R <br />R111111111111111111111111111111 <br />39- TANS IDS <br />TANK SIZE CHEMICALS TO BE STORES PROPOSED INSTALLATION <br />/C 5 o < -( DATE /946 <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />1111fill <br />I III] I 11111111 if <br />L <br />_ <br />APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />IIIIIIiltiifill fill 11111111111111111111111111111111111111i11111111111 <br />DATE <br />liffil11111111111111111111111111111111111111111111111111 <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: "I 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 <br />CERTIFY THAT IN THE PER RMAN <br />0 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALI 0 NIA. <br />QAPPLICANT'S <br />SIGNATU(E:TITLE <br />M G 0- - DATE <br />I*)� <br />,ixuicace the responsible party to be billed for additional PHS-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 />NameA47Ln ' i1i/�� k4,/2UClDf �S�o 14C 7-/S 2/IG <br />Mailing Address 1-.d. 1;bx f7' yJ F/2rmon7 CC( 9ys,3 �- <br />Day Phone Number <br />Signatu <br />EH 230 <br />s May 5, 1994) <br />1e-- <br />4 <br />Date <br />