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r • • <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 <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: /� CONTACT PHONE# �a7 �� 6 <br /> FACILITY NAME: �4t FACILITY PHONE#A57- <br /> FACILITY ADDRESS: 3/60 61 Aorw R4*41 CROSS STREET: <br /> OWNER/OPERATOR- ,PHONE: 707 3bo 13 <br /> CONTRACTOR NAME: . S PHONE: <br /> CONTRACTOR ADDRESS: 4440Y `? CA LICENSE # <br /> HAZARDOUS WASTE CERTIFICATE: ES NO WORKERS COMP # <br /> FIRE DISTRICT: �� PERMIT# <br /> BOARD OF EQUALIZATION <br /> TANIS ID# TANK SIZE CHEMICAL STORED PROP ED INSTALL DATE <br /> 34�157b/ o3?DS/f 2 yo SK v efF (o. <br /> d i 63 !o <br /> 0 oS f710K G / eC. <br /> 63lp S b <br /> ❑APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME W- N6A 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 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S CO SATION LAWS OF CALIFORNIA." <br /> IG APPLICANT'S SIGNATURE <br /> TITLE ;d DATE 3/I.q-h L, <br /> Indicate the responsible parry to be billed for additional EHD staff time expended beyond the 8-hour <br /> minimum installation payment. The party must acknowledge this responsibility for the additional billing <br /> by signature and date below. <br /> Name F W Date -e&. <br /> Mailing Address — S oISZEO! <br /> 7('Signature Daytime Phone -lo-?- %0-114 <br /> C. REQUIRED SUBM TALS <br /> 3 - <br />