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i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> APPLICATION FOR UND RGROU DA EK <br /> STORA H TA I 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 q <br /> MAY BE <br /> LETTER IS SENT 70 PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR 70 THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION <br /> � GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> I <br /> EPA SITE p DO NOT WRITE IN ANY SHADED AREAS. <br /> F <br /> PROJECT CONTACT & TELEPHONE #rt1 <br /> FACILITY NAME <br /> I A <br /> ADDRESS <br /> 1 Z4 PHONE # <br /> 1 <br /> L CROSS STREET <br /> I O <br /> T HE ERA70R <br /> r m1 <br /> C CONTRACTOR NAME - PHONE �! <br /> N CONTRACTOR ADDRESS 'C PHONE <br /> 7 �— <br /> R HAZARDOUS WASTCERTIFIED IFIED CA LIC #3�� �6 <br /> A 'YES NO CLAS <br /> T ...DISiRICT� Q WORK.COMp.>i$ 6 <br /> O BOARD OF EQUALIZATION PERMIT p <br /> R <br /> TANK I q <br /> 39- TANK SIZE <br /> T 39- O 00p CHEMICALS TO BE STORED <br /> _ A 39' �^ —� —. fic �. .ter, PROPOSED INSTALLATION <br /> K 39- ll DATE <br /> 39- -_ <br /> 39- <br /> A APPRj)- '� APPROVED WITH CONDITUONCS) <br /> N PLAN REVIEWERS NAME ,y ,.(§8E ATTACHMENT WITH CONDITIONS) DISAPPROVED <br /> APPLICANT MUST <br /> CO PERFORM ALL WORK IN ACCORDANCE WITH SAN JOgOUIN C(%1NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOANT COUNTY P I����� f <br /> THE PERFORMANCE OF THE LIC HEALTH SERVICES. OWNER OR LICENSED <br /> SUBJECT TO WORKER'S CpgproRK FOR WHICH T IS PERMIT AGENTS SIGNATURE <br /> COMPENSATION LA IS ISSUED, I SHALL CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> "I CERTIFY THAT IN TH CALIFORNIA," ALL <br /> AL NOT EMPLOY ANY PERSON,IN SUCH A <br /> COMPENSATION LAWS OF HIRING OR SUBCONTRACTING SIGNATUREACERTIFIES NNER AS OTHE BECOME <br /> FOLL <br /> CA FO WHICH THIS PERMIT IS ISSUED, I SNALL EMPLOY PERSONS SUBJECT TO WORKERS <br /> OWING: <br /> APPLICANT'S SIGNATURE: <br /> T I TLtFSkk&s <br /> Indicate the res I DATE <br /> Payment. The parry responsible party to be billed for a - - <br /> l Y must acknowledge this res ddltIona( PNS-EHD staff ti <br /> Name �,;1 Ponsibility for the additional bill Pendbd beyond the 8 hour minimus installation <br /> L✓, g Y signature and date below. <br /> Mailing Address 2 <br /> Day Phone N <br /> unbar � v�� / — <br /> Signature <br /> EH 23 008 C ev 12/13/95, UST Reg's May 5, 1994) <br /> Date 9--711 <br /> Z <br /> _znZ <br /> 4 <br />