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ti <br />SAN 41QUIN COUNTY PUBLIC HEALTH S$kICES <br />NVIRONMENTAL HEALTH DIVISIO <br />APPLICATION FOR INSTALLATION PERMIT <br />v PeNA,b7L- P-&� ► � arc, <br />THE APPLICATION FOR INSTALLATION Of UNDERGROUND STORAGE TANKS !S ONLY VALID FOR THEQALENOAR 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 TIME, ONE YEAR EXTENSION MAY 8E GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS y� 3 <br />EPA SITE # PROJECT CONTACT 8 TELEPHONE # �'ap IG �J r <br />F FACILITY NAME V PHONE # /r /p 1 ��- <br />A `9 ! J <br />ADDRESS <br />I I c r• nc o R.> v V <br />L CROSS STREET �.. <br />IJ'C'� ' <br />YOWNER/OPERATOR V�I / MrW� �PHONEC CONTRACTOR NAME PHONE # I �� V� <br />0it Otp <br />N CONTRACTOR ADDRESS .D x Lot— (�I� ✓, CA LIC # Z%g CLASS <br />T W <br />R HAZARDOUS WASTE CERTIFIED TES NO WORK.COMP.# <br />A <br />C FIRE DISTRICT PERMIT # ti <br />T <br />0 1 BOARD OF EQUALIZATION # <br />R <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- <br />T 39• 4 GATE <br />A 39- 4 AA <br />N 39- j <br />K 39- r z <br />39- —� <br />39- <br />3 111111111111111111 ItIll I III I fillI I I I I I I I I III 111111 <br />L APPROVEP APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A �c (S E TTACHMENT WITH CONDITIONS) /� Q <br />N PLAN REVIEWERS NAME DATE <br />11111111111111111111 111111 <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 "'WORK FOR <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORIIANCE�F'C 'WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORN <br />APPLICANT'S SIGNATURE: <br />Indicate the responsible party to <br />payment. The partyf j t acknowla <br />Name I I k vP, , <br />Mailing Address T , V • <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev 12/ <br />UST SYSTEM DRAWING <br />I� TITLE r I / DATE <br />billed for additional PHS -END staff time expended beyond the 8 hour minimum installation <br />this responsibility for the additional billing by signature and date below. <br />ST Reg's <br />TI0116�16/ <br />4 <br />Date <br />