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F, <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 PHS -END REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME 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 be billed for additional PNS-EHO staff time expended beyond the 8 hour minimAa installation payment. <br />The partA mu%t acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing A <br />Day Phone <br />Signa <br />EN 23 008 (Rev 1/7/92) WP <br />CIIVL: D + <br />14a) Jk <br />.Be�„ � � y-" P.. 3ci i��n SAN J A Li i,(�I:NiY <br />Y wft <br />PU <br />y^rci c`-i� �.w�t� `�4�`� • E 53�11 IiEAi."(Fj r�l�IC�t ��4�- <br />EPA SITE S <br />PROJECT CONTACT S TELEPHONE all <br />F <br />FACILITY NAME <br />C -I <br />PHONE B _ <br />A <br />C <br />ADDRESS <br />i <br />L <br />CROSS STREET r �� <br />i <br />T <br />Y <br />OWNER/OPERATOR& <br />PHONE <br />'L <br />C <br />CONTRACTOR NAME <br />— <br />PHONE <br />Ldeaa <br />0 <br />N <br />CONTRACTOR ADDRESS <br />rn <br />CA LIC S <br />CLASS ' <br />11-iR <br />T <br />HAZARDOUS WASTE CERTIFIED YES <br />NO <br />WORK.COMP. <br />A <br />C <br />FIRE DISTRICT <br />PERMIT <br />T <br />0 <br />BOARD OF EQUALiZATiowde <br />R <br />' I' TANK ID A" <br />TANK S i ZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />34. <br />DATE <br />T <br />34- <br />A <br />39- <br />l <br />N <br />39- <br />K <br />39- <br />39-._�.='' <br />39- <br />P <br />II�I <br />L_ <br />APPROVED <br />APPROVED WITH CONDiTION(S) _ DISAPPROVED <br />A <br />N <br />PLAN REVIEWERS NAME - <br />(SEE AT AC T WITH CONDITIONS) <br />DATE' <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 FOLLOWINGS "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 CALIF 1A." <br />APPLICANT'S SIGNATURE: <br />TiTLE DATES <br />Indicate the responsible party to be billed for additional PNS-EHO staff time expended beyond the 8 hour minimAa installation payment. <br />The partA mu%t acknowledge this responsibility for the additional billing by signature and date below. <br />Mailing A <br />Day Phone <br />Signa <br />EN 23 008 (Rev 1/7/92) WP <br />CIIVL: D + <br />14a) Jk <br />.Be�„ � � y-" P.. 3ci i��n SAN J A Li i,(�I:NiY <br />Y wft <br />PU <br />y^rci c`-i� �.w�t� `�4�`� • E 53�11 IiEAi."(Fj r�l�IC�t ��4�- <br />