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01/08/2004 08:23 <br />20946834.q3 FIFTH FLOOR PAGE 04 <br />R 7- 7 -7 <br />SAN JOAQUIN COUNTY MAR ?, 4 2004 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALL pF aP1913- 14A7r,1--,`,L H <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEARN 111 Wig B <br />ESSU1--D. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EX.TENSION "'HIRTY <br />DAYS PRIOR TO THE END OF THE CALENDAR YEAR, A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br />LETTER. <br />JOF— <br />• r �' y % <br />r <br />A . i <br />c <br />FACILITY ADDRESS: -717 RA STzr--F—'r <br />rj �P►. <br />' <br />CONTRACTOR . <br />r r . • I / / <br />0 <br />E E r Og <br />Am <br />DISTRICT;HAZARDOUS WASTE CERTIFICATE: YES NO <br />FIRE <br />■ <br />BOARD OF EQUALIZATIONIIIIIIIIIIIIt _ <br />i"mu <br />0 APPROVED L3 APPROVED WITH CONDITIONS 0 DISAPPROVED <br />attachments) <br />PLAN ■ ■ DATE <br />APPLICANT MUST PERFORM ALL WORK INA <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE1?AR7MENT. OWNER OR LICENSED �iGENI"S <br />SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF T14E WORK' FOR WHICI I TI -TIS <br />PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO W01RJU-f-2S <br />COMPENSATION LAWS OF CALIFORNIA.". CONTRACTOR'$ HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br />FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUIED, i SHALL <br />EMPLOY PERSONSSUBJECT IBJECT TO WORKER'S. COMPENSATION PAWS OF CALIFORNIA." <br />TITLE O WtV v DATE -92L, 4 j.3 <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 --hour <br />:minimum installation payment. The party must acknowledge this responsibility for the additional billing <br />by signature and date below. <br />Mailing Address <br />Signature <br />L/NT M o N T <br />-3- <br />Date ` 3 <br />Daytime Phone aoil <br />