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0 <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />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 />nn NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />' / f�. -�'�� 21-2 <br />PHONE # <br />FACILITY NAME <br />tI Y' <br />' cL <br />ADDRESS j 8 <br />t-4 <br />v <br />- % - <br />CROSS STREET � - <br />�r <br />�.�! <br />OWNER/OPERATOR <br />'7' 6 i"szlt�/ <br />PHONE # <br />CONTRACTOR NAME <br />f , <br />PHONE #+,<_ <br />CONTRACTOR ADDRESS7 �Y <br />CA LIC # <br />ei <br />CLASSE. Y <br />0 <br />WORK.COMP.# <br />HAZARDOUS WASTE CERTIFIED <br />YES <br />PERMIT # 144/ <br />FIRE DISTRICT �,C <br />f�Z. 14�lC'� <br />BOARD OF EQUALIZATION # <br />TANK ID # <br />TANK SIZE CHEMICALS TO E <br />STORED PROPOSE DATETALI/ ATI ON <br />39- <br />- <br />39- <br />39- <br />39- <br />39- <br />39- <br />APPROVED APPROVED WITH CONDITIONS) <br />DISAPPROVED <br />_ <br />(SEE ATTACHMENT WITH CONDITIONS) <br />DATE <br />PLAN REVIEWERS NAME <br />M I ffiffiffi----- IIIIrl Irl-11!i!iiMii7OF <br />APPLICANT MUST PERFORM ALL WORK IN <br />ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATION <br />"I CERTIFY THAT IN <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br />BECOME <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO <br />THE FOLLOWING: <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />EMPLOY PERSONS SUBJECT TO WORKER'S <br />"I CERTIFY THAT IN THE PERFORMANCE <br />OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL <br />COMPENSATION LAWS OF CALIFORNIA." <br />— <br />- TITLE <br />%11N A DATE"L <br />APPLICANT'S SIGNATUR : ---" <br />Indicate the responsible party to be bi ped for additional PHS-EHD staff time expenaea Deyona the o nuui mil uuu <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name GiJl�r Limit[ llo.� Crr/1'Ne�iJ e c ) <br />Mailing Address / 2 Z-5 ; l C2 Z2 <br />Day Phone Number 9 �_I,;d r <br />Signature i z <br />EH 23 008 (Rev 12/11/95/UST Reg's May 5, 1994) <br />G! <br />Date 6e /Lix)y <br />