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RECEN EDD <br /> 08 <br /> ENVIRONMENTAL HEALTH DEPA T T HEALTH <br /> SAN JOAQUIN COUNTY PERM!T/,E VICES <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 <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO 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 EHD UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> GF[ 9? <br /> 3 <br /> FA-CIL T NAME: LI Y HON# <br /> FACILITY AD R SS ),gj,3, C OSS STREET: <br /> AA T <br /> OWNER/0ERATO <br /> VwA <br /> C T CTORME: MO <br /> h �� 3- �1 <br /> CONTRACTOR ADD SS: C LIC NS # <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS X . COMP <br /> f#�-- f c2 <br /> YES NO Wr - I e7� 016 1 b1 CJ <br /> FI TRICT: PERMIT# <br /> W <br /> 4 <br /> BOARD OF U <br /> 03 <br /> T NK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> PV V LLP <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA." <br /> Applicant's Signature S <br /> Title Date a/ — / <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name C, Date — ( ®— <br /> Mailing Address "� t •4 --3 C)Z <br /> Signature Daytime Phone 21"�--20 — t <br /> Revised 061108 3 <br />