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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 /> t7 LLj <br /> EPA SITE # - 1 PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME 'VA-SIl/ C�L(�, L ® (G PNONE # <br /> A <br /> C ADDRESS LI CJ <br /> I <br /> L CROSS STREET A G` . 6 �, <br /> I � <br /> T OWNER/OPERATO I ' "� PHONE <br /> Y <br /> C CONTRACTOR NAMEWAV12W[?- , I PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS �I Zago <br /> CA LIC # �® CLASS G <br /> T <br /> R HAZARDOUS WASTES CERTIIFIED YES NO WORK.COMP.# <br /> A 1,J-fL ® ' W <br /> C FIRE DISTRICT , PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 11111111 I l l l i l l l l 1111111111111 <br /> TANK ID # TANK SIZE CHEMICALS 0 BE STORED PROPOSED INSTA AT ON <br /> 39 '0 L• IBJE L, DATE <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 111111111111111111� 111111111111111111111111111 1111111111111111111111111111 111111111111111111111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 1111111111111111111111111 I I I I I I I I I I I I 1111111111111111111111 1111111!I I I11111111 i I1111111111111111111111111111111111111 <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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFO <br /> A. <br /> APPLICANT'S SIGNATURE: TITLE %&LIU DATE ® A423 <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. BThe party l!m��uss!t, acknowledge this responsibility for the additional billing by signature and date below. <br /> Name <br /> Mailing Address H. <br /> Day Phone Number I <br /> Signature Date / z7 G7 <br /> EH 23 008 (Rev 12/ 3/95, UST Reg's May 5, 1994) <br />