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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <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. <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 />Indicate the responsible party to <br />payment. The party must acknow_ljo, <br />dined for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />thi sponsibility for the additional billing by signature and date below. <br />Mailing Address e / /L L 0 <br />Day Phone Number ` 3 �5 <br />Signature <br />EH 23 008 (Rev 12/13/95, UST Reg's May <br />2 W <br />Date 2® <br />EPA SITE # ' I PROJECT CONTACT & TELEPHONE # , lag 7,1 ,S'--743-7g77t, Ity-5 <br />F <br />A <br />FACILITY NAME 1 1 C--7(-® 1\f <br />PHONE <br />C <br />1 <br />ADDRESS 1'7'76 Pry Z—(P—D®CIC C. cr' <br />J <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />PHONE <br />C <br />O <br />CONTRACTOR NAME &Wd—roE�D 1F=t c 45-Atv1ez^t1wEw7??.e- <br />PHONE �tl <br />N <br />T <br />&fov <br />CONTRACTOR ADDRESS ®® 2-�16n�r�c WL -Lc <br />CA LIC # CLASS <br />R <br />A <br />HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.#AIC 1987O <br />C <br />FIRE DISTRICT PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION 4ILi �C / <br />R <br />1 <br />litlllllllllllllllillllltlll!! <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSE <br />39- DATE <br />T <br />39- L)::�rr 7,0 coo 677L Leq,15 7T WE_r�so <br />A <br />39- 12° 1 <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P t I! 1 TtT1T n jlj-(TjTITT <br />L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />_ <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />liilllllilllil11111iilllltl 111111lI II 1! lI11 IIII 1111 ! 11 ! Ili t!I I111lIIIItIIIINIiIIl11 I !1! !! 1lltlllltlll il! <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 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 Vf? P CP46OOr DATE <br />Indicate the responsible party to <br />payment. The party must acknow_ljo, <br />dined for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />thi sponsibility for the additional billing by signature and date below. <br />Mailing Address e / /L L 0 <br />Day Phone Number ` 3 �5 <br />Signature <br />EH 23 008 (Rev 12/13/95, UST Reg's May <br />2 W <br />Date 2® <br />