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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> " ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> } ERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEA2 IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> OR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE :,RANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> ## DO NOT WRITE IN ANY SHADED AREAS. <br /> i A SITE # PROJECT CONTACT 3 TELEPHONE 0 <br /> ILITY NAME 0 PHONE <br /> RESS L I e l V <br /> SS STREET AC 0 <br /> ER/OPERATOR PHONE <br /> NA <br /> A i lJa✓`11(962- -3 `b1 (=, <br /> 1 TRACTOR NAMEPHONE # <br /> 1 RACTOR ADDRESS a O� j3pig CA LIC #c �3� ] CLASS 1-11 A Z /'-4 <br /> RDOUS WASTE CERTIFIED YES_ NO w WORK.C`CMP.;* �1�_ <br /> 5 +\ <br /> DISTRICT i PERMIT # <br /> 0 OF EQUALIZATION # <br /> t <br /> Ililllllllllllllllllllill <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> II 1�COO +cJ 31 ,--1 OATEN <br /> iC,cc,n <br /> I <br /> APP:RVAA APPROVED WITH CONDITION(S) DISAPPROVED <br /> ( EE ATTACHMENT WITH CONDITIONS) / <br /> REVIEWERS NAME DATE / <br /> llllllllllllll ilil II i IIIII111111111111111111111111111111111111111111111tllllllllllllllill Illlllllllllll <br /> MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> lid COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> O WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> THAT IM THE PERFORMANCE OF FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> IOM LAWS OF CALIF IA." <br /> IS SIGMA Tl1RE: <br /> ;'-4— TITLE / / DATE <br /> i <br /> responsible part-y to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> PWLY ast acknowledge this responsibility for the additional billing by signature and date below. <br /> 7 <br /> Reg's May 5, 1994) Date <br />