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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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-END REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE #C-Al i JT 1 � PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME I'{�� 6!1 i l �' I PHONE #�p ,� <br /> A � L I <br /> C ADDRESS 7 L ' <br /> LCROSS STREEET<- f►_Ci <br /> I fid` <br /> T I OWNE OPE ATOR PHONE <br /> Y -111 <br /> C CONTRACTOR NAME �Tr h G` PHONE <br /> N CONTRACTOR ADDRESS <br /> r C, 1 / CA LIC # i /c� CLASS�� <br /> v G I <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.#�O <br /> A <br /> C FIRE DISTRICT �G ' ��- I PERMIT # <br /> T - �l <br /> 0 BOARD OF EQUALIZATION # 0 <br /> R <br /> 1111111i1lIllillllllilllllllll <br /> TANK ID TANK SIZ / C�CALS TO BE STORED PROPOSED INSTALLATION <br /> 39 i /Z,E�Oc>Y�-I- DATE <br /> T 39 /n_ O GO �+ <br /> A 39- <br /> N 39- <br /> K <br /> 9 K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> APPROV ( �/ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A EE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ., DATE ?— <br /> Ililllltlltiillillllllllil II111 Illll I i II I II111 Ilil II I I III IIIllllllllilillllll Ilii 1 Illillllilll <br /> ,7- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> j 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 COMPENS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PE ORMANCE TH 8X FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CA F A." <br /> i <br /> APPLICANT'S SIGNATURE: TITLE DATE 2 <br /> Indicate the responsible party to be billed for additional PHS-E80 staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name <br /> Mailing Address 1 <br /> Day Phone N r — Z <br /> Signature �� Z--3 <br /> u <br /> Date <br /> EH 23 008 (Rev 1/7/92) WP �N� vdvc <br /> 11/ r"01?� <br /> J " <br /> ti <br /> �� V,-) o,4 <br />