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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT NAS BEEN ISSIED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR TEAR IF A LETTER IS SENT TO PHS-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR TEAR. A ONE TEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IV ANY SHADED AREAS. <br /> EPA SITE 3 Cq 4) PROJECT CONTACT L TELEPHONE irn`ES S//✓G154 <br /> F FACILITY NAME /�, �, /y��;y Z? PHONE f Z,� / $3 z '/,Z,35 <br /> A y� <br /> C ADDRESS <br /> 1 _ <br /> L CROSS STREET �i1c GFs� - <br /> I <br /> T OWER/OPERATOR PHONE Z <br /> T f/�/i✓2 C� N6�i✓� ?/ S, f�. /2 /SG- Sg7�G <br /> C CONTRACTOR NAME /c/ /�� fro /C;U L-�Z. PHONE i <br /> 0 <br /> N CONTRACTOR ADDRESS 912 An,eJ ,qL,F CA LIC s.39 .S � S OLAa 3 -i�ar..--,���•1 <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO_ WCRX-CCMP•s <br /> A <br /> C FIRE DISTRICT PERMIT = <br /> T <br /> 0 BOARD OF EOUALIZATION ? <br /> R <br /> TANK <br /> IllilllillTANK Iillllllilillil <br /> ID 3 TANG SIZP GAC FCNE ✓LYS TO GTO�REOD L PROPOSED INSTALLATION <br /> ly39- LDATE S <br /> T <br /> 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> P <br /> ( _ APP APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE A T WITH CONDITIONS) DATE ZL/ <br /> N PLAN REVIEWERS NAME <br /> 11111111111111111111 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RUNES AND REGULATIONS OF <br /> SNI JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •1 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 YORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> Of CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO YORK'ER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> APPLICANT'S SIGNATURE: TITLE DATE - <br /> EN 23 000 (Rev 1/7!92) WP Page 3 <br /> •�u8 ` z-- <br /> 3 <br />