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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <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 <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# <br /> FACILITY NAME:. ^hL Jo q Q V) N RT'p FACILITY PHONE# <br /> REatl;7nAc- C E7 N 7=X <br /> FACILITY ADDRESS: CROSS STREET: <br /> ; .c4i!} q F- M>/R.TL. E S7- q s�os' <br /> OWNERIOPERATOR: PHONE: <br /> SA ).4 U-C>A Q v t J,1" I= RTD <br /> CONTRACTOR NAME: PHONE: <br /> 9rDJ?AL) , CeS luc, 32o-��R---o�83 <br /> CONTRACTOR ADDRESS: ) 6 S-3 W. jFL_ 5jEcuJil CA LICENSE# <br /> G:.A11ZIDF_ NA j C.A 9 0 q Lj 9 <br /> HAZARDOUS WASTE CERTIFICATE: I JRKEERCOMP <br /> AJArTIo�t�►V 1NSut��tcE Co- <br /> YES ✓ NO CAQ00155-7131 <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> sRA,B R7�4�35�. S <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> O n L <br /> a L_ �� <br /> 0 f <1 <br /> O APPROVED ❑APPROVED WITH CON0171ONS ❑DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature � 6�� <br /> Title,lC o "rRAG7-0r? Date A--L0 L} <br /> Indicate the responsible party to be billed for additional EHD 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 F ' E:—J-Z;QS'D A.[ k+Y D EA-I J I J C-4 1 NrC'_ Date 4— 9 —144 <br /> Mailing Address O <br /> Signature Daytime Phone, <br /> T---.__.3 ^^ it II'1 <br />