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06/17/1998 17: 38 209-825-4251 B/W INN CF MANTECA PAGE 05 <br /> 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-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY DHS-EMD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE 0`o�l Q G AJ Q2 PROJECT CONTACT B TELEPHONE M <br /> A FACILITY NAME GXk <br /> ADDRESS B G12 r - , ' 'y �� T r' <br /> L CROSS STREET LQ O A V,� <br /> I H <br /> T OWNER/OPERATOR //�� PHONE Y <br /> U CONTRACTOR NAME � .� N �� SG v 1 PHONE <br /> ce <br /> N CONTRACTOR ADDRESS �� l�. k `I N per,` CA LIC / L'7� - I-7 CLASSA_M- cu ti) 4o <br /> T '`e FLR 1, 1. -eV <br /> R HAZARDOUS WASTE CERTIFIED YES_ NO WOAK.COMP,g <br /> A <br /> C FIRE DISTRICT <br /> i PERMIT g <br /> 0 BOARD OF EQUALIZATION B <br /> A <br /> 39- <br /> TANK ID A TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> T 39- DATE <br /> A 39- <br /> N 39• <br /> K 39- <br /> 39- <br /> 39. <br /> P <br /> L _ APPR EO APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) l �� <br /> N PLAN REVIEWERS NAME DATE 7/1 <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. DINER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT [M THE PERFORMANOf THE LARK FOR NI CH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- I� <br /> APPLICANT'S SIGNATURE: U TITLE rKV,. (5jDATE DATE -1 9 <br /> Indicate the responsible party to be billed for additional PHS-ERD staff time expended beyond the 8 hour minimus installation <br /> PSY""t. The party RAlat acknowledge this resP/9�si bility for the additional billing by signature and date below. <br /> w.n.�LCYI G(1 0 11 L- e // (r1�r ' o l\tl '5A1s b oci Q <br /> Mailing Address P()�Yb,'O�x L•+"'fC�'1��'f]k ,5 e,A t"1`.QI� g'2 1 <br /> Day Phone Number G-\. o— [„ ,J— [� v �^— �� �o �Z �S 7- 3 <br /> Signature Date <br /> EN 23 008 (Rev 12/13/9 , U T Reg's May 5, 1 1 <br /> 4 <br /> JUN-17-1996 17:20 209 825 4251 96% P.05 <br />