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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: CONTA_CT PHONE# <br /> %a7'74,5 /a <br /> FACILITY NAME: - _ _ / FACILITY PHONE# <br /> Fiz / <br /> FACILITY ADDRESS: 3/�0 RIO- CROSS STREET: <br /> OWNER/OPERATOR: U PHONE: <br /> Za7- 360 -/3 <br /> CONTRACTOR NAME: , L s PHONE: /48S <br /> CONTRACTOR ADDRESS: 2OyCA LICENSE# <br /> `7 / 7 q Z" <br /> HAZARDOUS WASTE CERTIFICATE: ES NO WORKERS COMP# <br /> Duty 3497AS�?. <br /> FIRE DISTRICT: �� PERMIT# <br /> BOARD OF EQUALIZATION <br /> TAN ID# TANK SIZE CHEMICAL STORED PROP ED INSTALL DATE <br /> 34oS15�o/ o3?D5/t 2 Zo <br /> d 40f / 63 `lo CokY.• v <br /> 0 of S" IL GGx� r eta <br /> G39p S b� /G <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE z—1—0 <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 /> SIGNA'T'URE 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,1 SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COM SATION LAWS OF CALIFORNIA." <br /> IGAPPLICANT'S SIGNATURE <br /> TITLE Cho/Pkt I'd DATE ?Asir L <br /> Indicate the responsible party 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_a5E 1�}j/ ( Date <br /> Mailing Address <br /> 71'Signature Daytime Phone -1o7- <br /> C. <br /> o7-C. REQUIRED SUBM TALS <br /> - 3 - <br />