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SANJOAQUIN Environmental Health Department <br /> COUNTY <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 <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 /> PROJECT CONTACT: CONTACT PHONE # <br /> FACILITY NA FACILITY PHONE# <br /> 4e, L 5 <br /> FACILITY ADDRESS : / „O �� CROSS STREET: <br /> 4 q5a � <br /> OWNER/OPERATOR : PHONE : <br /> bxai9;5� <br /> CONTRACTOR NAME : X PHONE : <br /> 11A <br /> CONTRACTOR ADDRESS : CA LICENSE # <br /> 6Nc ass <br /> HAZARDOUS WASTE CERTIFICATE : WORKERS COMP # <br /> YES NO9 16730 7 <br /> FIRE DISTRICT : PERMIT # 2 p �� ►� 53 2 �1 ` '� � �P <br /> � c;cli �i I'p ' r 1'l�vt -� � -F r � �k L � 2 � u Za'► -; > � -C;J , � ` l _ <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> eva 0 W7 � G moi <br /> Z- r , <br /> L ead <br /> ❑ APPROVEDAPPROVED WITH CONDITIONS [I DISAPPROVED <br /> i (see attachments ) <br /> PLAN REVIEWER'S NAME DATE 2 <br /> APPLICANT MUST PERFORM ALL WORK4R*AdC0RDAlME 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 <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS CALIFO IA." <br /> Applicant's <br /> Signature <br /> Title ( _T�� Date <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 D ^.1 Date /B — 3 <br /> Mailing Address N �. c77 <br /> Signature 4LDaytime Phone/lam <br /> 3of8 <br />