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1. . c 003 ° -7 <br /> SAN JOAQUIN,COUNTY <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 EXTENDED INTO THE NEXT CEAALR. ApONE ME.ONE YEAR IS <br /> MAY BE GUESTING RANTED BYIS EXTENSION THIRTY EH UPON RECEIPTOFAYS F THIS P EIOR TO THE END OF THE CALENDAR <br /> LETTER, <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> CONTACT PHONE# <br /> PROJECT CONTACT: <br /> FACILITY PHONE# <br /> FACILITY NAME: racv <br /> CROSS STREET: � <br /> FACILITY ADDRESS: fn, ,,r 4 PscadzrO <br /> PHONE: (L4 08) 3`j9 - y aC9� <br /> OWNER/OPERATOR a iI Q,yy Ocz c <br /> CONTRACTOR NAME: aaIC v' i+roleum CDnlro�ocS PHONE: �/j� - 9ya - 8(08( <br /> 4 -b LA &L(-S Inc . f}lf3/C <br /> CONTRACTOR ADDRESS: CA LICENSE# 3� (.P 75 CLASS:io-Ha <br /> 9-6o es f Cn g.so <br /> HAZARDOUS WASTE CERTIFICATE: ES nNO WORKERS COMP# c/ O 111 54 is <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> 2-0, 00C) cellon �.1ccSAR�vt9 (x�) �c 11 ZCvz <br /> '2 opo - 9c'tIon C7as C�t) , � cscl �c�tt Zooms <br /> []APPROVED PROVED WITH CONDITIONS EIDISAPPROVED <br /> (seeall chmenI with conditions) <br /> PLAN REVIEWER'S NAME 01 DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW .AND RULES AND REGULATIONS OF SAN JOAQUII` <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 WORK FF CALIFORNIA.*FOR WHICH THIS PERMIT 5 ISSU,,D!RING I SHALL PERSONS SUBJECT TO WORKERS COMPENSUBCONTRACTING SIGNATURE CERTIFIES THE SATION^I CERTIFY THAT IN LAW�SS OF ALIFORNIA E PERFORMANCE OF THE <br /> APPLICANT'S SIGNATURE:--74 TITLEYOI I I LA✓1R�CA4 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 IDWIITV,hysignature and date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number <br /> Signature Date_ <br /> EH 23 008 (RPkv 3/15102L <br /> C`Y" <br />