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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-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # CAL 000152228 PROJECT CONTACT & TELEPHONE # Tim .Gipson 209-461-6337 <br /> F FACILITY NAME J&L Market PHONE # 0 - T--7877- <br /> A <br /> C ADDRESS 8115 S . E1 Dorado St . French Camp 95231 <br /> I <br /> L CROSS STREET Matthews Road <br /> I <br /> T OWNER/OPERATOR James Fisk PHONE #209-982-0 <br /> Y <br /> C CONTRACTOR NAME ELITE IV CONTRACTORS PHONE 109-461-6337 <br /> 0 <br /> N CONTRACTOR ADDRESS 27 36 Teepee Dr . #C Stocktoni CA LIC 0660076 CLASS A , B , C , -lO ,Haz <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES X NO WORK-comp.f29-94-9347 <br /> A <br /> C FIRE DISTRICT French Camp I PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # 1 y _ c)?,y� G� <br /> R I 1 <br /> I11111illltliltl111l111lI11111 <br /> 39- ,'d TANK J` If,, — � TANK SIZE �� Un eac�ed gaS TO BE SSORED PRQpOSEDINSDATE� LA7I0N <br /> 39- '�7 — C,, 3,, t 2255—rs-- — <br /> n 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> I ? <br /> L ! APPRQVED V/APPROVED WITH CONDITION(S) DISAPPROVED <br /> A f �SEE ATTACHMENT WITH CONDITIONS) J p <br /> N PLAN REVIEWERS NAME ' DATE C/ v <br /> III11I111111111111111111 IIll fl 111!1 111 1111 I 1111 II 1 I I 111111 111!111 1 I ilf 111111111 Iliflillll <br /> F <br /> COPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN UNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> N JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> HE 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 CALIFORNIA." <br /> APPLICANT'S SIGNATUR�,—�zl—— <br /> TYLE V . P DATE <br /> im ipson , L , g <br /> Indicate the -esponsibLe party to be billed for additional PHS-EHD 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 James Fisk , Owner <br /> Mailing Address 8115 S . El Dorado St French Camp Ca . 95231 <br /> 209-962-0697 <br /> Day Phone Number <br /> Si---ture / <br /> Date <br /> -T <br /> EH I2 <br /> 3 .008 (Rev 1 /92) WPT_ cc►ic �C� 0 1 <br /> I, <br /> LKG ` es(a� -o( <br /> 2� �s `�-- �cl✓�m�ss���� �2g��c�C� SG�a1/ C� ,,��ZC�lo1,�d' �c� ����� <br />