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ENVIRONMENTAL HEALTH DIVISION <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-EHD 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 & TELEPHONE # <br />F FACILITY NAME PHONE # <br />A <br />C ADDRESS <br />I <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR PHONE # <br />Y <br />C CONTRACTOR NAME PHONE # <br />0 <br />N CONTRACTOR ADDRESS CA LIC # CLASS <br />T <br />R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br />A <br />C FIRE DISTRICT PERMIT # <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- DATE <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39 - <br />'ill <br />P <br />L _ APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />III IIIIllliiiiliiiil I 11111111111 <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: "1 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 DATE <br />Indicate the responsible party to be billed for additional PHS -END 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 <br />Mailing Address <br />Day Phone Number <br />Signature Date <br />EH 23 008 (Rev 1/7/92) WP <br />K <br />