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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVI5ION <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 CALEROAR YEAR IF A LETTER IS SENT TO PNS-EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION NAY BE GRANTED BY PNS-EHD UPON RECEIPT OF TNS$ LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE a PROJECT CONTACT Z TELEPHONE # 9ov G MA SSA(z0 T '3 SS¢Z3644 <br /> A FACILITY NAME (3Eflcon/ �#t�qZ PHONE d zo 1 gz3 134-4- <br /> C AOORESS .470 N. M,41/v Oi-F 1WA.1l/T"6:cA <br /> I <br /> L CROSS STREET LA /Vl ED�. --- -- --- - <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y U`T 10-Anit,4,e !NC - Zoy 583 3 Z35 <br /> I"� l <br /> TOR NAME— J N OZ 71L)( I. _ I PHONE #� g2513 /74/v/ <br /> CONTRACTOR ADDRESS 9700 c- 5%?avJ 10y'i� 93 11 I u Ll # (o g'Z7 4 Z CLASS A '3 H/� <br /> HAZARDOUS WASTE CERTIFIED YES •� NO LORK.COMP.# C c- <br /> p �j Z ZII 6 <br /> TRICT PERMIT # <br /> EQUALIZAT ION a11111illlllltlll11111TAN9�10 S TANK SIZE CHEMICALS TO BE STOREDDROPOSED IN27AllATI- q(0 _ /4-000 G ft S o u n C- DnTE 9-�s•I <br /> T 39- FJo 14000 GASo�wE —�-- is-9�— <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39. <br /> 39- <br /> 3 tln T11111 <br /> iiilTtJTiffl�L APP VE) APPROVED W1TN CONDITI011(5) OiSAPPROVED <br /> A ( (SEE A ACHMENT WITH CORDITIDNS)N PLAN REVIEWERS NAMDATE 1 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM JOACUIN COUNTY ORDINANCES, STATE LADS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUELIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR YM1CH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 19 SUCH A HAMNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRINS OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> °1 CERTIFY THAT IN THE PERFORMANCE OF THE MIRK FOR WHICH THIS PERMIT IS ISSUED, I SRALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- <br /> APPLICANT'S SIGNATURE: 17-� TITLE I `Q�. EG(2• DATE <br /> Irdisate the ruporsible Para to be blued for additional PHS-END Staff time expended beyorC the 8 hour minis instaLlation <br /> payment. The parry tknowledge this responsibility f9r the additionat bitting by signature and date below. <br /> mn <br /> Nae � S E' n/G(NEE�f VC yy <br /> Waiting Address Zo? w. AvQ�T/I'olE�(TA,( AV. #Zo3 B vrQB�N� <br /> OaY Phone NUffber Z 36¢4 1 <br /> Si"rure <br /> EH 23 006 (Rev 12113/95, UST Reg'a May 5, 19%) Date <br /> 4 <br />