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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 <br /> MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PMOR TO THE END OF THE <br /> CALENDAR 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 /> PROJECT CONTACT: ��� 1 Sftlll=IU 5 <br /> CONTACT PHONE# <br /> yas- 3:y5-- zsuo <br /> FACILITYNAME: 7-E(eueW S'62C Z.Z37 - 3ZIQG FACILITY PHONE# ZOq — 0t 3q _ OCo'Irj <br /> FACILITY ADDRESS: </qy3 5. S�A+e P1 q1f, 5j6c1CfaHtj CROSS STREET:, Al2m l2D <br /> OWNERIOPERATOR PHONE: <br /> Z<•1 3 =37U.3 <br /> CONTRACTOR NAME: PHONE: <br /> Cres. E 1 d 12u r-1'ZS'- 355- Z8 ZCa <br /> CONTRACTOR ADDRESS: 144-Iti, 't�U8Set1 CA LICENSE# 714 q 38 CLASS: <br /> Mul ,1 eo A SZTJ A <br /> TANK-11)# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> 1 /Sr70v AS Cr <br /> 2 10 C)60 af4 gntinje- <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> (see attachment with condition // <br /> PLAN REVIEWER'S NAME DATE 1� �(0 0 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKERS COMPENSATION LAWS OF <br /> CALIFORNIA' <br /> APPLICANTS SIGNATURE: �l1tY G7/r(/YF'� f TITLEOAd44100 R.Jg~ATE &-G -03 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name Cjn)01120YY) Aq1 '5161 (ces zyc <br /> Mailing Address 'qqt& RvOc(( 12) Hwkd 'to , 04 98275 <br /> Day Phone Number_ 4/ - 3 5S - Z8 ZC.o <br /> Signature1 Date_ <br /> EH 23 008 (Rev 3/15/02) <br /> 4 <br />