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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> CH IT <br /> S BEEN ISSUED. A PEMIT MA <br /> THE <br /> BE EXTENDEAPPLICATION <br /> NTFOR INSTLLATION OF UNERGROUND O THE NAEXT CALENDAR YDEAR F A LETTER IS SENT TO EHD REQUESTING E TANKS IS ONLY I THIS EXTENSION THIRTY D FOR THE CALENDAR YEAR ID YSIPRIORFTO THE END OF THE CALENDARY <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# JeoO— ?3D — 99y8 <br /> PROJECT CONTACT: Yi��/ / <br /> FACILITY NAME: c � 45, FACILITY PHONE# v��f <br /> ,/ CROSS STREET: <br /> FACILITY ADDRESS: 37D0 H � fJ�rH�2V� <br /> PHONE: pg ?34— <br /> OWNER/OPERATOR <br /> D -OWNER/OPERATOR <br /> CONTRACTOR NAME: �t2 � �D PHONE: 1/D!J - g7z 866 <br /> CONTRACTOR ADDRESS: CA LICENSE# CLASS: <br /> O--%ME3 w12 54n�OSe e� jSo3�` <br /> HAZARDOUS WASTE CERTIFICATE: QYES nNO PWORKERS <br /> ERMIT# O MP J , <br /> FIRE DISTRICT: <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑DISAPPROVED <br /> (see 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:'I 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 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' p <br /> APPLICANTS SIGNATURE: �I TITLE DATE O Z Oz <br /> Indicate the responsible parttoe 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 <br /> Address <br /> 13--,;-?-0/ 11A- <br /> Mailing <br /> Day Phone Number l_ — <br /> 29- X999 �C�X <br /> Signature <br /> Date_ X12 <br /> EH 23 008 (Rev 3/15/02) <br /> 4 <br />