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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 /> FACILITY NAME: /��f FACILITY PHONE# <br /> 1006im-1 <br /> FACILITY DRESS: CROSS STREET: <br /> -�UI,U-Ktc kd 4eaWA-I-1v �4/,r 6P <br /> OWNER/OPER TOR: / PHONE: <br /> ,NIOUNT44414 �Looiz SQ(j CONTRACTOR NAVE. PHONE: <br /> byc 6.0� <br /> CONTRACTOR ADDRE CA LICENSE# <br /> 3 �p 11Z 7i �-Aqeoo jo-ti 103 106,S�0 <br /> HAZARDOUS WASTE CERTIFICATE: /' WORKERS <br /> COMP <br /> / 1 � / <br /> t, 4-^� z- '/ YES NO ` <br /> CiC'3 V tt <br /> FIRE DISTRICT: PERMIT# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> r cd o <br /> O<i <br /> ❑APPROVED APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see attachments) �R <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 <br /> PERFORMANCE OF THE WORK FOIR 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 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 C4,' ,1> I Dilate <br /> Mailing Address d P ,,I '8 2-0 t� Z r dC✓ . �- � 6 f � I <br /> Signature t�( dr(.[ h I Daytime Phone14 <br /> -- <br /> I; <br /> 3of8 <br />