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lsl� �. <br /> 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 /> FACILITY NAME: .Ata Jo/� QV1 N RTS FACILITY PHONE# <br /> u C.�/tl T•�1Q. <br /> FACILITY ADDRESS: CROSS STREET: <br /> 2 81} cj F— M>'RTL E .sT- q s�os <br /> OWNERIOPERATOR: PHONE: <br /> SA ),I SoA Q v i ,.t RTD �o c 0 4 S1 <br /> CONTRACTOR NAME: PHONE: <br /> p�T E-k Std h! �,� --0 8,3 <br /> CONTRACTOR ADDRESS: S-3 w. j=L.. 5jEqL*p>CA LICENSE# <br /> HAZARDOUS WASTE CERTIFICATE: I WORKERS COMP# <br /> YESy� NO EVeRGST KIAT104AL 1NswtAutF Co. <br /> ,41 001557131 <br /> FIRE DISTRICT: PERMIT# <br /> 1 `i — 2 3 7i c <br /> BOARD OF EQUALIZATION# <br /> sFZ�.S R7�4�35�. S <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> O o <br /> CD L, �t <br /> Cj � it <br /> 0 APPROVED ❑APPROVED WITH CON017IONS ❑DISAPPROVED <br /> see attachments 1 <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERF RM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS <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 PE�RSONS� SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature � o-1..- /�/ <br /> Title (`O t\L"TR A GT O 2 Date A--LCj--)L4 <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 1-r-13 1 NC'. Date 4— 91 —L4 <br /> Mailing Address D O <br /> Signature Daytime Phone�,,�f� --�Z 3 <br />