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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 ISSUED. <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 TEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> 7ADDRESS <br /> PROJECT CONTACT 8 TELEPHONE # <br /> ME My Mini Mart PHONE # (209) 941-2264 <br /> 756 N. Wilson Way, Stockton, CA 95202 <br /> T College Avenue <br /> TOR Annette Hoag (209) 474-7532 <br /> C CONTRACTOR NAME SEMCO PHONE # (209) 524-9653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 South 7th Street CA LIC # 449864 CLASS A, B, C, 061/D40 <br /> TuoRK.caHP.#046-0007108-99 <br /> R HAZARDOUS WASTE CERTIFIED YES X NO__ <br /> A PERMIT # <br /> C FIRE DISTRICT City of Stockton <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK !D At TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 002 91000 Gasoline 5/24 DATE <br /> T 39- 551 'Ay-nnn r'-03� <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- j <br /> 111 ffflTffffrnTffffffffM, <br /> P <br /> L APPROV APPROVED WITH CONDITION(S) DISAPPROVED . <br /> A � � SEE ATTACHMENT WITH CONDITIONS) G <br /> N PLAN REVIEWERS NAME E/� -<-� AK 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 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 /> "1 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 CALIFORNI <br /> APPLICANT'S SIGNATURE: 1 TITLE Agent for Owner DATE 5/12/99 <br /> Indicate the responsible party to be bitted for additional PHS-EHO staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name SEMCO - — <br /> Mailing Address 1217 South 7th Street, Modesto, CA 95351-9401 <br /> Day Phone Number (209) 524-9653 <br /> Signature Date 5/12/99 <br /> EH 23 008 (Rev 12/13/95, UST Reg's May 5, 1994) <br /> 4 <br />