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ENVIRONMENTAL HEALTH DIVISION <br /> irtEG� <br /> �1 AW/�TION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> MPS N�� V��,,�1\\���oN <br /> APPLICATkNoo,o� T;AIrA�Q�vCtf UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PERMC,]PC�^- NTO THE NEXT CALENDAR YEAR 1F A LETTER IS SENT TO PHS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR �f HE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. � L,,,_,, <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # (�/G 37Z lqy` ////V'YL LS^"Ile <br /> F FACILITY NAME PHONE #y/5-66y 3.37 <br /> 11A <br /> C ADDRESS _ <br /> 1 <br /> L CROSS STREET <br /> TOWNER P ATOR �J, PHONE # <br /> Y �- J1�. yis=66 - <br /> C CONTRACTOR NAME PHONE #9i/o—�T2Z_/Cj Sr.S_ <br /> 0 <br /> N CONTRACTOR ADDRESS JDloI SEA T LLLIP• �. CA LIC #M J779 1 CLASS <br /> T 1/0C6l 14 <br /> R HAZARDOUS WASTE CERTIFIED YES�� NO_ WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIIIIIIIIIINK <br /> AIIIIII111111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- Z — I $�,. I' 49t DATE_ <br /> A 39- rte— ,C�b <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A SEE A TACNMENT WITH CONDITIONS) a,� <br /> N PLAN REVIEWERS NAME _ DATE Af / <br /> IIIIIIIIIIIIIIilllll � 111111 � IIIIIIIII <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTDR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> �".��j <br /> APPLICANT'S SIGNATURE-.(/ ^"' � TITLE O u%/Y ti� DATE <br /> Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name u� }� y ! /' <br /> Mailing Address ��17 SR"tiI DUE44 D `tIf1 A !Cz& <br /> Day Phone Numbe41/7/922) <br /> -7 <br /> Signature Date J �C / 3 <br /> EH 23 008 (Rev <br /> 3 <br />