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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 CALENDAR YEAR IF A LETTER IS SENT TO PHS-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 PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # 972. yO6 - 20653 R, <br /> F FACILITY NAME pA0 f (u(�' D-6A r0a 4 Lef$ PHONE # Lxl - Q15�- -7 <br /> A <br /> C ADDRESS (.78 N W1156p) W4 CA, <br /> 1 <br /> L CROSS STREET rrev- mo t bhrGe�' <br /> 1 <br /> T OWNER/OPERATORQ A PHONE # <br /> Y Q , G , ID F-ob4 4 WK <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESSCA LIC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO_ WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMIC LS T�O 8,OE STORED PROPOSED INSTALLATION <br /> 39- �JO,0�PIL /a pea r-� 1-[ MI klM.ClU�GO�[Jd DATE 7.001 <br /> T 39- —AcnL ! <br /> A 39 <br /> m L[. <br /> K 39- O � 09 lYU <br /> 39- <br /> 39- <br /> LIIIIIJIIIIIII <br /> S.zcr CB11(Jw TI a ay( _ APPROVEDy APPR IT CO DI 1 !( ) s D APPR6YE �S <br /> A !/ DATE <br /> EE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME <br /> fldI A�III IIS Q <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THI RMT <br /> IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF A IFORNI A." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IERF)OFMANE OF T RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF R IA." <br /> APPLICANT'S SIGNATURE: 'V TITLE MLI J\AT DATE Z -® <br /> Indicate the responsible p y to be lied for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must ac nowledge is responsibility for the additional billing by signature and date below. <br /> 4 <br /> Name Foc4 t"-j <br /> Mailing Address 67 a A�. w l I, /S( 1 <br /> Day Phone N r - "!5-2. 44"r1 <br /> SignatureDate <br /> EH 23 008 (Rev /13 g' May 5, 1994) <br /> 4 ' <br />