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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 EHD 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 /> PAME:iA G_tJ� RT'so � gt�-sQca-t. . <br /> FACILITY NAME: sghL joA QV)N RT'p FACILITY PHONE# <br /> REG V C„x=-7IllT x <br /> FACILITY ADDRESS: CROSS STREET: <br /> ;.314cj E. MXR.TL E sr q s�os <br /> OWNERIOPERATOR: PHONE: <br /> SAW U"OAQ v t >s F—::' <br /> CONTRACTOR NAME: PHONE: <br /> Ff-57--i')e1ok4 310-(�..2�'--©x"83 <br /> CONTRACTOR ADDRESS: ) G S3 V,/. f=L- 5jEC►t* CA LICENSE# ? I �� <br /> C;,^ 1z©I; r%LA C^ qo J 6 <br /> HAZARDOUS WASTE CERTIFICATE: IrCOMP# <br /> FRES 1J/4TIowiAl. 1n1,SURANcE Co. <br /> YESy� NO A I OO I!S 713 M <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> sRR,B R��4z35•�. S <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> C7 L <br /> C, L_. A J <br /> d >; 'At <br /> ❑APPROVED ❑APPROVED WITH CONDITIONS ❑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.n...- <br /> Title ("-O tNL"TR A G?"0 2 Date 4-- C? —)!4 <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—=- k±> Df I J j ) C S 1 NC Date — 9 -- 144 <br /> Mailing Address /1I D DaA <br /> Signature Daytime Phone ��l D --0?213 -31s.5 <br /> ^---=- I n-.i1Nwn- Z <br />