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• <br />Ll <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <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 PNS -END REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF TNR CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE 1N ANY SNARED AREAS. <br />EPA SITE # PROJECT CONTACT i TELEPHON # <br />F FACILITY NAME.0 , C — PHONE t <br />A <br />C ADDRESS <br />I <br />L CROSS STREET Aq <br />I <br />Y . OWNER/OPERATOR PHONE # ` <br />� <br />LILL <br />C CONTRACTOR NAME IA PHONE 0 — <br />0 <br />N CONTRACTOR ADDRESS CA LIC # CLASS <br />T <br />R HAZARDOUS WASTE CERTIFIED YES_LZ NOWORK.COMP. <br />C FIRE DISTRICT PERMIT N <br />T <br />0 BOARD OF EOUALIZATIOW # <br />R <br />Ililnililn�ili��nnnnllli <br />E CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />TA K I # TANK SIZE!DATE -777 <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />IIiI��� �R <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A ` ' (SEE ATTACHMENT W CONDITIONS) DATE <br />N PLAN REVIEWERS NAME <br />IIIIIIIIIIIIIII�III� ����� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD CE 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 TH 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 CALIF IA." /� <br />LLAPPLICANT'S SIGNATURE: TITLE CCU. U. /- � DATE <br />Indicate the responsiote party to De DltMU Tor swiviGna{ rna-enu •cavy 1-11ev V^tm +o.+..aT..-... .... <br />The partx mugt acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing <br />Day Phone <br />Si <br />1-2& -9 <br />EH 23 008 (Rev 1/7/92) WP / <br />