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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 ISSUE <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION KAY BE GRANTED BY PMS-END UPON RECEIPT OF THIS LETTE! <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # G1 fi. <br /> F FACILITY NAME S / PHONE # �`� <br /> A <br /> C ADDRESS (a/lO� ^,60 <br /> 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y � ° /onJ Q()( - �13i-a -� <br /> C CONTRACTOR NAME PHONE # oi _ <br /> 0 <br /> N CONTRACTOR ADDRESS ..� 0 (3 6 'Fr- x. nAi.-G a,_ CA LIC # �� CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES ',C No_ WORK.COMP.# <br /> A 1 <br /> C FIRE DISTRICT I.C1'�r- PERMIT # , <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO RE STORED PROPOSED INSTALLATIO. <br /> 39- / .nnn am.//r7.r. DATE <br /> T 39- /- - // �,/'I-�ccrrn / -a q.._ •� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L APPROVED X APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SE TT HMF,NT WITH CONDITIONS) �J <br /> N PLAN REVIEWERS NAME Ag DATE <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL 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 CALIFORNIA." <br /> q c <br /> APPLICANT'S SIGNATURE: A,^ b— -3�ii_ TITLE Lkc DATE r / c <br /> Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond the B hour minimum installation <br /> payment. TTnhe party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name T�/1/}'L1/a`3E�/✓� Ski djo�', <br /> Mailing Address (/YJ /�� r �If—kON7� npP't <br /> V <br /> Day Phone Number LIJ �< r <br /> Signature-- <L,. -0 < (' Date �z/f 9(4 <br /> EN 23 008 (Rev 12/W95, LIST'Reg s May 5, 994) n / <br /> LIST SYSTEM DRAWING �. .� W/�tJ ����✓ �� I - „{, Q .11����`- �_ <br />