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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-EHD 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 /> TC SITE # A L G c o I O Ci l PROJECT CONTACT & TELEPHONE # <br /> �� 7-0q- 33-3a4 <br /> ILITY NAME �.L � Q�hC1✓ �nL <br /> Q C PHONE #Zvq °9' 2i d <br /> RESS ` � (SS STREET L Cw cti' � _Cfti� _VAER/OPERATOR _ <br /> 1_ s. <br /> PHONE # <br /> C CONTRACTOR NAME �D b�, f <br /> 0 E Te I d(�\V1 Q PHONE # <br /> N CONTRACTOR ADDRESS <br /> T CA LIC # CLASS <br /> R HAZARDOUS WASTE CERTIFIED YES NO <br /> A WORK.COMP.# <br /> C FIRE DISTRICT <br /> T PERMIT # <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 111111111111111111111111111111 <br /> TANK ID # N I�TANK SIZE CHEMICALS TO BE STORED <br /> 39- PROPOSED INSTALLATION <br /> T 39- DATE <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111 <br /> L APPROVED APPROVED WITHCONDITIONS) <br /> A _ <br /> DISAPPROVED <br /> N PLAN REVIEWERS NAME (SEE ATTACHMENT WITH CONDITIONS) <br /> IIII11111111111111111111 II IIII III I I II III I I I I DATE <br /> II I <br /> III III fill lifffffffffffiff-Ifffl-ITI-1 <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 PERF NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI RNI " D <br /> APPLICANT'S SIGNATURE: I\. TITLE �w►6W s T�IIU• q <br /> DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation a <br /> The party must acknowledge this res y payment. <br /> possibility for the additional billing by signature and date below. <br /> Name U «arms.y- �rr1G. A do <br /> _ �1 1✓1 <br /> Mailing Address 5a7 LJ S� C1 2-30 Day Phone Number_ ZO q- S-83 - 3 a u 7 U "l <br /> Signature <br /> _ Date_ -I -Cl S-q <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />