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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />E <br />NVIRONMENTAL HEALTH DIVISI� <br />APPLICATION F IN ELATION PERMIT <br />bt <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALIDR 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 TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS -END UPON RECEIPT OF THIS LETTER. <br />00 NOT WRITE IN ANY SHADED AREAS 2 <br />EPA SITE # PROJECT CONTACT b TELEPHONE # W� 'L f/ 1,s <br />F I FACILITY NAME PHONE # 51(] b 5 D U U <br />A 7 <br />` <br />ADDRESS US` W <br />1 j <br />L CROSS STREET V w <br />1 <br />YOWNER/OPERATOR �u ` 5 �y p/1 (� % n ' 1 _ / PHONE #C57fO` I <br />C CONTRACTOR NAME G , PHONE # q <br />0 <br />N CONTRACTOR ADDRESS o x lot CLASS <br />T (A <br />(Pj <br />AR HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# fj 0 l% <br />C FIRE DISTRICT PERMIT # <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />111111111111111111111111111111 - � <br />39- TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />T 39- <br />OATE <br />A 39- <br />N 39- <br />K 39- n <br />39- <br />39- <br />P 1111 iT(T 11 I <br />LPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A i (SEE TACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAMEDATE / 7 <br />11111111111111111111 11111 <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 IFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PIFORMIAN�F T K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIfORNIAJI J / <br />APPLICANT'S SIGNATURE: <br />ndicate the responsible party t <br />ayment. Th /party t acknowl <br />ame ��I I - ,AM <br />s i l i ng Address . <br />ly Phone Number l w <br />'gnature <br />1 23 008 (Rev 12/13/95, UST Reg' <br />;T SYSTEM DRAWING INFORMATI N <br />TITLE DATE <br />billed for additional PHS -END staff time expended beyond the 8 hour minimum installation <br />this responsibility for the additional billing by signature and date below. <br />to Z <br />4 <br />ri <br />Date <br />