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RECEIVED <br /> � !' q 2022 Environmental Health Department <br /> SAN ��g10AQlJIN <br /> COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 /> 7 C41 <br /> FACILITY NAME : /��f FACILITY PHONE# <br /> �CO — A10017 <br /> FACILITY ADD ESS : CROSS STREET: <br /> 1 S 0 y w G' ? /i1`4', tC 4 WAI <br /> OWNER/OPER TOR: / PHONE : <br /> CONTRACTOR NAVE , PHONE : <br /> by C 66 76 0 /0 <br /> CONTRACTOR ADDRE CA LICENSE # <br /> 3 V0 11/01 7il; 49400 josti 103 106 ,S 0 <br /> HAZARDOUS WASTE CERTIFICATE : /' WORKERS <br /> COMP`# / <br /> / 1 � t, {-^ �, %/ YES NO Ci C'3 V tt <br /> FIRE DISTRICT: PERMIT # <br /> TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> 7 4 ; r cd o <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) �R <br /> PLAN REVIEWER' S NAMEDATE `'" L� � � <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 <br /> PERFORMANCE OF THE WORK FO <br /> ,R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL NIA." /^ <br /> Applicant's Signature <br /> Title r' r /� Date <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the &hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. ' <br /> Name A p I Date <br /> Mailing Address d C1 7 ) dC✓ p <br /> Signature Daytime Phone -- V <br /> ( <br /> I; <br /> 3of8 <br />