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V W <br /> 4 E ONMENTAL HEALTH DIVISION <br /> o <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT 1 �•/ <br /> AYS <br /> APPLICATION FOR INSTALLATION OF LA,�+C;-jjND TANKS ARE ONLY VALID FOR THE GALE <br /> NDAR YEAR iN WHICH 1T HAS BE <br /> ING THIS <br /> A PERMIT MAY RE EXTEN"pEDCALfNDARINTO ers�� ALONEAYEARA--ZF A ONE TIMEER IS SENT TO ExTENSiOH KAYPBE GRANTEDUBYIPHS-EHD UPON RE[E1PT�QF THIS LEITER. <br /> PRIOR to THE EUD OFT E <br /> DO NOT WRITE IN AiY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT TELEPHONE # <br /> C 'ra 'te 701e� PHONE # <br /> F FACILITY NAME c-" <br /> C ADDRESS (.�1'�'l",) ��.J r21� � t G <br /> I <br /> L CROSS STREET <br /> 1 PHONE # ilfl C nv �✓j C� <br /> T OWNER/OPERATOR t'� <br /> Y �4C r" Cl/ r_ I PHONE # <br /> C CONTRACTOR NAME +-CN <br /> 0 CA LIC # CLASS <br /> N CONTRACTOR ADDRESS V(Z7 J • <br /> TrEs NO WORK.COMP.#Pl l 'Z" C c <br /> R HAZARDOUS WASTE CERTIFIED <br /> A PERMIT # F-P Cl 14 0 -1' <br /> C FIRE DISTRICT ti,,IAIF`�3I, e Mt��C1�u'+ ' <br /> T <br /> 0 90ARO OF EQUAL I ZAT I ON <br /> R <br /> INSTALLATIONTA <br /> TAUK ID � TANK SIZE CHEMICALS i0 8E STORED <br /> A <br /> DTE <br /> 39- —�'- <br /> 1 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P APPROVsD APPROVED WITH CONDITION(g) DISAPPROVED <br /> L (S E ATTACHMENT W1 � CDNDIT9DNS} <br /> A DATE <br /> H PLAN REVIEWERS NAME <br /> �' Illlll <br /> liiiililllllil lllili <br /> APPLICANT MUST PERFORM ALL IN SERVICES. O4?IERHDAAN JOAQUINCENSED AGFNT"S NTY 51GNATURESCERTIFIES, STATE ATHE FOLLOWIUG:RULES ANDIRCERUFY THATIN <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH 5ErH A MANNER AS NOT SU <br /> THE PERFORMANCE OF THE WORK FOR WHICH OFICALi ORNIAg"15CONTRACTOR'�SLHIRINGMOROSURCONTRACTINCNSIGNATURE CERTIFIES OTHE FOLLOWING' <br /> SUBJECT TO WORKER'S COMPENSATION LAWS <br /> '"T CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO 1��R S <br /> COMPENSATION LAWS OF CALIF <br /> �^� ATE —LjE� <br /> 711LE <br /> - <br /> APPLICANT'S SIGNATURE: ✓ �' `�' �"�� �iA IL�'r Cbf�d � <br /> Indicate the resPonsible Party t0 billed for additl dd4 lorull billingilry efpna� Bed and dateond ebeloQur minimum installation payment. <br /> The party must acknowledge this reSpor+sibility for thea t <br /> Name <br /> Meiling Address <br /> Day Phone r <br /> Dote <br /> Slgneture ' <br /> EH 23 009 (Rev 1/7/92) WP <br /> 3 <br /> DO 4021 <br /> - - - E>GF�LhNA1-jN " 1211 <br /> ROBERT` H. LEE & ASSOCIATES 1 �[L ' <br /> 1 137 NOFtTl1 Mcb{1wrll SLVII. <br /> MrAtAJMA,CA 9054 <br /> 101.7nr,-1660 19 . <br /> CHECK <br /> PAY r'� "�Z '' ``, f' DvlJar,s� AMOUNT <br /> AMOUN <br /> or- t[T <br /> 01 <br /> Ff1C l"HIIl:R � <br /> 1A1WNdI0N.40UAMf nrNcr. I Vol /" I EO GO DAYS <br /> ME IC4 Rivu <br /> PE i Al LMA CA'P053 <br /> 1: L 0141,0 2 18i: 0 50q 2 AD L011e <br />