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6--19-1 999 2':02PIM FR51 <br /> low, SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> "ME AP%ICATiON FOR INSTALLATION OF UNDERGROUND STCRACE TANKS IS ONLY VALID FOR IMF. CALENDAR YEAR IN WHICH 1T ;RAS SEEN iSSUED. <br /> A miRMIT MAY 3E EXTENDED INTO THE NEXT CALENOAR YEAR If A LETT8R IS SENT TO PNS-EID REQUESTING THIS EXTENSION THIRTY OATS <br /> PRIOR TO THE END OF 7NE CALENDAR YEAR. A ONE TIME, CNE YEAR EXTENSION MAY BE GRAWrED BY PWS-ENO UPON RECEIPT OF THIS 4MER. <br /> 00 NOT 1.817E IN ANY SHADED AREAS. <br /> { <br /> EPA SITE ,5CJ PROJECT CONTACT & TELEPHONE d .2l/ Ljq <br /> F FACILITY NAME L`l <br /> C i ADDRESS <br /> I I <br /> j 1 CROSS STREET <br /> IIi <br /> i . 4WN'eRIOfERFTOR POCK 0 <br /> j �^C t CONTRACTOR NAME PHONE # cl <br /> 4 I CONTRACTOR AOORESS2M(�) CC CA LIC 4 �v'1(� I:LAss <br /> A HAZARDOUS WASTE CERTIFIZO YES NO t WD.FK.GCMP.1 ml <br /> C FIRE DISTRICT 1 PERNIT ;4 I <br /> 0 ' BOARD OF E"LIZATION 0 <br /> —{I11111111iTANK lt!!!!l1111t1! } <br /> ' 39• TANK [O 0 ' TA11KI�IlE k GNEMICALS t0 BE a'TOR"eD n� —`nowisEn <br /> � OATS A ATiONI <br /> 139• 1!K I 1__ 1 <br /> A 34 F <br /> I� N 39• _- <br /> !!!! I <br /> i P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A @G TACHMENT WtTN CONDITIONS) (i <br /> N PLAN REVIEWERS NAME `'-�-r�� �' �- I)AT: Z > <br /> I!IlI1lli!llli!!l13111l1illillllillilli! !!! T[lCT]1CTl1T1111!! <br /> APPLICANT MUST PERFORM ALL WORK [M ACCORDARCE WITH SAN JOAZJIN COUWTY OI19MCES, STATE u1WS, AND RALES AND REa LATICNS OF <br /> SAN JOAQUIN COUNTY WSLIC HEALTH SERVICES. OWNER 04 LIMM&S AGENT'S "aIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT 1N <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 159UED, I STALL NOT EMPLOY ANY PERSON IN SUCH A NANNFA AS TO WcONE <br /> ! SUBJECT TO WZRICER�S COMPENSATION LAWS OF CALIFORNIA." CONT2ACTOR'S HIRING OR SUBCONTRACTING SIGNATURE C_RTIFTFS THE FOLLOUING. <br /> "I CERTIFY 'HAT iN THE PERFORMANCE Of THE WORK r'OR W.iICH rItIS PERMIT IS ISSUED, I SHALL EMPLCY PERSONS SUBJECT TO WORKER'S i <br /> COMPENSATION LAWS OF CALI• NIA." ! <br /> � r <br /> APPLICANT'S SIGNATURE: TITLE DAT, <br /> indicate the responsible party to oe bitted for addr "t PHS-EHD staff time expended beyond the B hour winimmr inscalLation <br /> Payment. The party moat eeknewledge this responsibility for the additionaL bilLing by sirlature and date below. <br /> Name <br /> mai L ing Address �� �1.�� \5���\�� ` U✓�Sd ��.\�'X\ C� \1C� CJ� "�2 <br /> Dt one qumber <br /> Signature 7- 111 Date <br /> EH 23 008 (Rev 12/13!95, Lei, <br /> ts ,is May $, 1944) __ -` "' <br />