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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-END 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-END UPOI1 REEEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. -\ <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE57- <br /> { 4S S <br /> F FACILITY NAME <br /> A `� PHON # <br /> ADDRESS <br /> 1 24 q C.- <br /> 7/ <br /> ' C C <br /> L CROSS STREET <br /> I O p _ <br /> T HE ERATOR <br /> Y M 1 PHONE # <br /> C CONTRACTOR NAME _ s._ 7 '- Z <br /> 0 I . <br /> .c. :U PHONE. #— <br /> N CONTRACTOR ADDRESS fJ •� •'� <br /> T U A L #3� J CLASt: <br /> R HAZARDOUS WASTE CERTIFIED C <br /> A - YES__ NO__ <br /> WORK.COMP.#� / 7, <br /> C FIRE DISTRICT,,— o <br /> T PERMIT # <br /> 0 BOARD OF EQUALIZATION W <br /> R <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE <br /> 39- l� �� CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 7 39- l a tr r n <br /> A 39- ly 1G t DATE <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L APPROVED <br /> A APPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME (SEE ATTACHMENT WITH CONDITIONS) <br /> 11111111111111111111 I I I I I I I I I DATE <br /> IIII II I IIIIIII I I I I I <br /> APPLICANT MUST PERFORM WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, NO <br /> AND RULES AD REGULATIONS F <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 T IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON,IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LA CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 1 CERTIFY THAT IN TH <br /> COMPENSATION LAWS OF CA FO WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> APPLICANT'S SIGNATURE: <br /> TITLE >�/lC.t y/ /2- DATE�$-210 <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the 8 hour minimum installation <br /> Name <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> �'� — .� �� <br /> Mailing Address 047/ pp <br /> -, /4t STcclr Z , <br /> Day Phone Number wFr-7._ 1 17 ._ZC'_ `— <br /> Signature \ <br /> EH 23 008 ( ev 12/13/95, UST Reg's May 5, 1994) Date <br /> 4 <br />