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�5(L oa 56 -7 51 <br /> %W, SAN JOAQUIN COUNTY N .: <br /> ENVIRONMENTAL HEALTH 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 ISSUED, A PERMIT MAY <br /> BE EMENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE CALENDAR <br /> YEAR. A ONE TIME.ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> CONTACT PHONE# <br /> PROJECT CONTACT: <br /> FACILITY PHONE# <br /> FACILITY NAME: �t4ac NI <br /> FACILITY ADDRESS: CROSS STREET: <br /> 111a wY �escadQ.rD <br /> n n - PHONE: CIIV�� 399 - '18(0 <br /> OWNE JOPERATOR (� iI lMya [� <br /> CONTRACTORNAME: aalcn c,+rokux>1 CCOfiacFors PHONE: <br /> �vIDLQrS Inc . <br /> CONTRACTOR ADDRESS: } en q5 C),3 <br /> CA LICENSE# 39 (a5�5 CLASS DNA <br /> 930 c1p� <br /> HAZARDOUS WASTE CERTIFICATE: baYES nNO WORKERS COMP# 4 O 111 5 Lf b <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> 2-0, (DOC) - aUan G-tcLsakZvd WI) �n Zoc>z <br /> ZO oov - oJc�llon ' Comas Cit) 7escl 4 11 ZoOL- <br /> L]APPROVED OVED WITH CONDITIONS ❑DISAPPROVED <br /> ee attachment with conditions) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN <br /> COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION <br /> LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE <br /> WORK FOR WHICH THIS PERMIT IS ISSU D,I SHHALL_EMPLOY <br /> )PE(R�SONS SUBJECT TO WORKER'S COMPENSATION LAWS OF C�ALIFORNIA.- -7 <br /> APPLICANTS SIGNATURE:2 7,�t'J'.Ut"X ilk TITLE_ r' IU.MIQggQ C DATE S/ I <br /> u— <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 bitting by signature and date below. <br /> Name <br /> Mailing Address C4 3E . ^.c%1 3 --" .I -b 58 1 LAS G1ajiis CA- °/s-oac3- <br /> Day Phone Number 40� I ` co 18 <br /> Signature Date_ <br /> EH 23 008 (R@v 3115I07,YL <br /> .rJ�l66�NIP- 4 <br />