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ENVIRONWN�AL HEALTH DIVISION <br />APPLICATION FOR UNDEI�C WOUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOE TME ��' �.`, YEAR IN WIION IT MAS SEEM ISAI®. <br />A FtRMIT CAN It EXTENDED INTO THE NEXT CALENDAR TEAR IF A LETTER IS SENT TO ►YS -END UNINVITING THIS OITEMSION THIRTY OATS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A CNE YEAR -- ONE TIME EXTENSION MY RE RRAMT0 BY PNS -END UPON RECEIPT OF TNIS LETTER, <br />DO NOT CRATE IN AMT SNADED AREAS. <br />EN 27 000 (Nov 1/7/92) UE <br />iD (fu FL z3 <br />Pa" 3 <br />PAYmrtrr <br />JUN 0 5 1992 <br />SAN JOAQUIN COUNTY <br />I lii:1.IC; I IL.AI_Tf I SF!iVICF:S <br />3 `HVIROPJMIAL HLALII I DIVIYON <br />• C� <br />EDA SITE ! <br />PROJECT CONTACT Z TELEPIIOIE UT FOS-➢zB4O IU <br />SS E' 6rtJ <br />F <br />A <br />FACILITY TAME DUEL VU A Off/, 4 /7-u7- 0/t -/J <br />pom I Zo9 - p <br />1DWSS 3SOo ircY c4 s 7 <br />L <br />1 <br />uan srREET <br />T <br />0611M/OPERATOR <br />PNOE S <br />T <br />DEPT. or 2F loll <br />09- - oSs <br />C <br />0 <br />CONTRACTOR NAME <br />/ SIC-5S CoS <br />,v T C_ 7-10 <br />PIIawE S Fos -937-585 <br />M <br />T <br />CONTRACTOR ADDRESS12.0 , �� X ZFq SNUOuYA/y7/TRSI <br />339 S <br />CLASS <br />R <br />MA7ARDOIS WASTE CERTIFIED TES X NO_ <br />WORK -COMP" TWO. //y7SS <br />C <br />FIRE DISTRICT <br />PERMIT ! <br />T <br />0 <br />MOM OF EOIALIZATIOM / <br />R <br />IIIIIIIIIIIIIIIIIIIIII i <br />TANK 10 TO"SIZE cmlws TO E STORED PR[POED INSTALLATION <br />39- - '` . , o 00 6-X /_ Ord S O (INEDATE <br />T <br />39- - <br />.;z an (,AG <br />hl E56 <br />-'FVLL <br />A <br />39• <br />M <br />39 <br />K <br />39- <br />IIII <br />P <br />L _ APPROVED APPROVED WITH COIGITION(S) DISAPPROVED <br />_ <br />A (SEE ATTACIMEMT YITM CONDITIONS) <br />M PLAN REVIEW" NAME DATE <br />IIIIIIIIIIIIIIIIIIII 11111 <br />APPLICANT MUST PERFORM ALL WORK IM ACCORDANCE WITH SAM "AUIM COMTT ORDINANCES, STATE LAYS, AND RIM2! AID REGULATIONS OF <br />SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER CR LIQ AGENT'S SIGNATURE CERTIFIES THE FO.LOYINGI Of CERTIFY THAT IN <br />THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL MDT 8VLOT ANY PERSON IM AXN A MAMIER AS TO BECOME <br />ABJECT TO 4ORKER4 COMPENSATION LAYS OF CALIFORNIA.- CONTRACTOR'! MIRING OR SUBCONTRACTING SIGNATIBE CERTIFIES TE FOLLOWING: <br />•I CERTIFY THAT IM THE PERFORMANCE OF THE WORK FCR WHICH THIS PERMIT It ISSUED, 1 SWILL DOLOY PE"OU ABJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA. - <br />APPLICANT -1 SICKATUREl / TITLE .BAJA Gl7NTR6U70AJ DATE —Z2" <br />EN 27 000 (Nov 1/7/92) UE <br />iD (fu FL z3 <br />Pa" 3 <br />PAYmrtrr <br />JUN 0 5 1992 <br />SAN JOAQUIN COUNTY <br />I lii:1.IC; I IL.AI_Tf I SF!iVICF:S <br />3 `HVIROPJMIAL HLALII I DIVIYON <br />• C� <br />