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From 11/03/2008 15 30 #164 P 006/033 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN 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 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 /> FACILITY NAMCc FACILITY PHONE# <br /> Cam _ 6 <br /> FACIT Y DRESS: CROSS STREET: <br /> -'f3'q1 I <br /> OWNERIOPERATOR. PHONE: <br /> G c�-7 <br /> CONTRACTOR NAME: PHONE: <br /> r �rl6- 62�Y�- 14 <br /> CONTRACT(?R ADDRESS- CA CA LICENSE# <br /> �4k1iv� <br /> 1i4t`zc 't'.4.v� e t EF;it U. SES <br /> 4S`677 17 712Lr <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES }� NO W <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> su 2.1. <br /> cs�o a �a <br /> 0 APPROVED 0 APPROVED WITH CONDITIONS 0 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 /> k Applicant's Signature <br /> yc Title Aiffe,/d,__ /y/P 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 /> x Name 642WA- it- Date 1,f off <br /> X Mailing Address <br /> iK Signature Daytime Phone y--607_ej>2.2 c7 <br /> Revised 07/31/08 3 <br />