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SAN JOAQUIN <br />COUNTY <br />Environmental Health Department <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERM <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR IN WHICH IT HAS BEEN <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTEN N THIRTY <br />DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RE IPT OF THIS <br />LETTER. <br />PROJECT CONTACT: <br />CONTACT PHONE # <br />FACILITY NAME: <br />FACILITY PHONE# <br />FACILITY ADDRESS: <br />CROSS STREET <br />OWNER/OPERATOR: <br />PHONE: <br />CONTRACTOR NAME: <br />B&T Service Station Contractors <br />PHO <br />805-929-8944 ext 1002 <br />CONTRACTOR ADDRESS: <br />630 South Frontage Road, Nipomo, CA 93444 <br />j1A LICENSE # <br />902034 <br />HAZARDOUS WASTE CERTIFICATE: <br />xxx YES <br />WORKERS COMP # <br />90685282017 <br />FIRE DISTRICT: P/EAMIT # <br />TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br />❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN AC PIT <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, RULES ANL) <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HE LTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br />FOLLOWING" I CERTIFY THAT IN THE PERFO MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED., I SHALL NOT EMPLOY <br />ANY PERSON IN SUCH A MANNER AS O BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />CONTRACTOR'S HIRING OR SUBCONT ACTING SIGNATURE CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE <br />PERFORMANCE OF THE WORK FOR W CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />Applicant's Signature <br />Title <br />Date <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8- ur minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature an d e EPVEE Name Dae <br />Mailing Address II it l r On,n <br />LU IU <br />Signature <br />Daytime Phone <br />ENVIRONMENTAL HEALTH <br />3 of 8 DEPARTMENT <br />