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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # Jo6 �C�KCT\A 1 --)Iq- 572-(o Z7 <br /> F FACILITY NAME Ie� 60 CPHONE # <br /> A <br /> ADDRESS <br /> I 1950 CAST NV..aC V_ A,tG . <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME M/�NESrj <br /> 0 L.aJI'V--0,4µC.-+CAL S .,U <br /> EFVCES PHONE # �_31O _ 595 -4555 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO_ WRK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> IIIIIIIIIIIIIIIIIIIIIII1111111 <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 1 Z.,O0 n LA NL L1 LE DATE <br /> T 39- 2.0000 („A,L %C-S_ 7 "Cl.F <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L APPROVED _X_APPROVED WITH CONDITION(S) DISAPPROVED <br /> A —t- (SEE ATTACHMENT WITH CONDITIONS) _ <br /> N PLAN REVIEWERS NAME O tt -a..2 DATES ` <br /> 111111111111111111 [[[11111111111 I I I I I I I I[Irl 1111111111 1 1 1 1 1 <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: "I 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 WRKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." , <br /> APPLICANT'S SIGNATURE: d-(<ADb TITLE��w�- Pet_ CH6iwCe^P-,DATE <br /> 4Edu,C9 <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour mini mm installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name <br /> Mailing Address <br /> Day Phone Number <br /> Signature Date <br /> EH 23 0/0;8�(Rev <br /> ��l/7/n/�92) WP <br /> W 0.1tT17�l�8Y14Z��-�' Q.�B7�?GC. ���/L � � N�� _ .,,[_��� �r- '�"✓ "Stc2��J2h� <br /> Q �U.eccF>� �1 vt XViL,(�G-I! ,ae. �e S��'l �` �tW3ZG / v�-✓YLS. <br />