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5-27-04; 8:43AM; ;925 55, 7888 # 7/ 34 <br /> 031 051 2004 16:18 20946834330 FIFTH FLOOR ® PAGE 07 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION P®Of UNDERGR6UND STORAGE TANK INSTALLATION.PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND 67ORACE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH cr HAS BW <br /> IMUS. A PERMIT MAY BE EXTENDED Iwo THE Nexr CALENDAR YEAR IF/1 fS SENT To END REQUESMIG THIS MMENSION THIRTI <br /> DAYS PRIOR TG THE END OFTHE CALENDAR YEAR. A ONETIM ONEYEAR EJCrEN9f0N MAYBE GRANTED BY EHD UPON RecaPT OF THIS <br /> LETTEpt <br /> PROJECT CONTACT: AW C. .n �,4[ COWAkC'T Pxopm# <br /> NOL 6 <br /> a AC1Lr17Y XAW: 5,3 , sc��,t FACUXrY.P1rOMWC } r <br /> rIFAc t' ADDREss: CRoss snvxT: s�- <br /> O► NEI2IUPEItATOR PHONE: <br /> CONTACTOR NAIvM: ONE= (C1ZS) <br /> COMMACTOR"DRESS: r4qtSgCA L7[CENSE# �7 <br /> X4 OUS WASTE CWRTMCAIXjNOWa . M S COAW <br /> FM nISnUCT_ xER T# <br /> �o QJF ZQU.AXMA.TXON# <br /> TAM M# TANK SX'L]E CHEMCAL STO .PPOP(3sED WSTALL DATE .' <br /> ,coo C,., ,3!' �' —•tS-- . <br /> Q APPROVEDPROOF Nvrm Commons CI.7DLSA. PROVED <br /> fNir <br /> (see attachments) <br /> UPLAN REV EWER'S NAMM, �7 DATE <br /> APPLICANT MUST PERFORi f ALL WRK IN At, W, H COUNTY ORDINANCES,STATE <br /> RULES AND S.ANJO.AQUkTCOLWIY'ENVIROMEIT. FMALTHDEPARTMENT.OWMORLICM0EDAGENT'S <br /> SIGNATURE CERIVM UIE FOLLOWING'I CERTIFY TBATIN TM PERFOFMANCE OF THE WORK FOR V4nCa THIS <br /> .PERMIT"IS ISSUED.,I SHALL NOT EMPLOY'ANY"I',ERSON M SUMA AMMM AS TO BECO?a SUBJ$CT TO Y7 MXER-s <br /> COMFEL~TSA1'I01T LAWS OF CALIFORNIA."CONlRA,CTOR'SCr OR SUBCONTRACTMG SIGNATURE CMTRrMS 1. E <br /> FOLLOWING I CERTW THAT DT 1M E PERFORIIIlANCE of TEE WORK FOR WEffCH TIA's PERMIT IS ISSUED I SjALL <br /> E©M+PLTOTY/-�,PeE�RV}SO,N(tS[`S�U�/BJJ>E�CT�{To W�f.+�ORE03WS COI TSA.TXCffLAWS CALLICORNIA." <br /> G 31 Pj.Jii V.{.tiA'16'if� F��:Vi�'�M VJ.aii . . • . ;'ti• . ..r .•1'... , , <br /> TITLE 17' WW2— <br /> DATE —05 <br /> Indicate the responsible party to be billed for additional EM stafl'time expended beyond the 8-hour <br /> minimum installation payment,The party must acknowledge this respansiibility for the addi#ional billing • <br /> by signature and date below. <br /> Name -t:�6,t:L 8, SI►c J Af` G fl y Date_ 10- 1-7- 4 <br /> MmlingAddres 2Z evje-0or(A. C& QfcFN <br /> Signature 4 Daytime Phone `'f i� •v- � <br /> - 3- <br />