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i ! � � •. ! � !. i � � L 1. 1 •. ! ! <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-EHD 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 />EPA SITE # <br />F FACILITY NAME <br />A <br />C ADDRESS <br />I <br />L CROSS STREET3 UL <br />I <br />T OWNEYOPERATOR <br />Y ®®..w <br />C CONTRACTOR NAME <br />0 <br />N CONTRACTOR ADDRESS r l <br />T <br />R HAZARDOUS WASTE CERTIFIED <br />A <br />C FIRE DISTRICT <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />DO NOT WRITE IN ANY SHADED AREAS. <br />PROJECT CONTACT & TELEPHONE # <br />i <br />d <br />a <br />r <br />TANK ID # T S Z CHEMICALS TO BE -STORED PROPOSED INSTALLATION <br />39- _ _ a DATE <br />T 39- e <br />A 39� i l <br />N 39- _ t( _ <br />K 39* --4� -- is as <br />39- ea as <br />39 <br />P <br />L _ APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) _ <br />N PLAN REVIEWERS NAME 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 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: Z';• .fc i TITLE` ' ` DATE r t1's <br />T <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name <br />Mailing Address <br />Day Phone Number, <br />Signature Date <br />EH 23 008 (Rev 1/7/92) WP <br />G4 3 <br />%�Yl? t <br />c W�a� <br />