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a 0 <br /> LE-NVIRONNIENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATIO gmpy4r <br /> APPLICATION FOR INSTALLATION OF LACM�7k:kJJND TANKS ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH ;IT HAS BEEN,I,SU—-- <br /> A PERMIT MAY BE EXTENDED INTO TX--- KEXi CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSI'bO T . TT DAYS <br /> PRIOR TO THE END OF THE CALENDAR r:AR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT vF THIS LETTER. <br /> DO NOT WRITE IH ANY SHADED AREAS. ENVIRONMENIALHEALTH <br /> PERMITISERVICES <br /> EPA SITE # �T d L7O 2� PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME �. PHONE # <br /> A II <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET ��� <br /> I <br /> T OWNER/OPERATOR ) PHONE <br /> Y <br /> C CONTRACIOR NAME �- I � I PHONE <br /> N CONTRACTOR ADDRESS LA LIC # CLASS, <br /> T <br /> R HA2ARDOUS WASTE CERTIFIED .-S NO WORK.COMP.# �) <br /> A <br /> C FIRE DISTRICT 'w� r,4 PERMIT # F qj4 ©Q-5'_'�. <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> [IIfIICIl111ffIIIIIIIIIflil111 <br /> TANK ID # n��-TANK SIZE CHE ICALS TO BE STORED P .NSTALLATION <br /> 39- �tlwr ylks jp �C L- h �QATE <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> I I I I <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ���, L.,C-� F �' '� �.� I� DATE l*- 2 <br /> Iflllflfllllllllllll I �I 1 I111111 JI <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 111 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF NIA." <br /> APPLICANT'S SIGNATURE: TITLEJ7Le,*.L CVNIl( ATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party mist acknowledge this responsibility for the additional billing by signature and date below. <br /> Name <br /> Mailing Addresses 1I�AAT�" f� tl� � ii�AlMF51�lT�, M <br /> Day Phoner { • �i ' '�)) <br /> Signaturer1 •GC. p-S5 aGIG Nei Date l f <br /> EH 23 008 (Rev 1/7/92) wP <br /> Cr�nCl c'�40r1' <br /> 3 <br />