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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 #C 17L _�I` �g'��G PROJECT CONTACT 8 TELEPHONE <br /> F FACILITY NAME 't c C)«r PHONE #•Z _ a 30 <br /> A <br /> C ADDRESS <br /> I - <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # {� <br /> Y <br /> C CONTRACTOR NAME ��L ✓ N J �uC PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESSK14og Q 6 CA LIC #J Q Z CLASS —AA <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT F �tS c A-tG PERMIT # 3� <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- f DATE <br /> T 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A SEE, ACTHMEKT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME a�/� �� �� l fC i DATE <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 THIS PERMIT IS ISSUED, I SHALL 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 /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFAfil&l <br /> ORNIA."APPLICANT'S SIGNATURE: I VP��� TITLE �AGf� DATE f lZ��� <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> / . f <br /> Name Ct�©!�hi ( � ��Age? �l1 <br /> Mailing Address no IS \ C tta r rtq Ir <br /> Day Phone Number <br /> Signature Date <br /> EH 23 008 (Rev /13/95, UST Reg's May 5, 1994) <br /> UST SYSTEM DRAWING INFORMATION <br /> ad, <br /> �z� ce � � v�►S <br />