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• f� y <br /> SAIN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TAMXS IS ONLY VALID POR THE CALENDAR YEAR IN WHICH IT HAS BEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR `{EAR If $, LETTER 5S SEN' i0 PNS-S.'AD RE0V'E9'TlMG T'h iS EXTEwalCm T15'I'ATY OAT'S <br /> PRICR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-ENO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE A PROJECT CONTACT E TELEPHONE ASl�I)t }.I�RDI-7L C 707 93--a9e2q <br /> FACI L I TY NAME ifvl , V cF.gTl= � L.L_ c_ PHONE A9�5 - <br /> ADDRESSDACI 'j C_ ICF �� '��%4• ON <br /> CROSS STREET Cj I7 -I <br /> CANER/OPERATOR PHONE A <br /> mai 7Ro M Rig �A 9�5 9�8- 300 <br /> CONTRACTOR NAMEi�L�Ia/ C 1 J C y PMJNE A -707 6 ,/3 — Z 9� <br /> CONTRACTOR ADDRESS 6l,! 4 D Tp C M<.'r DF<0 0 CA LIC A L/ : 57!5 j, I CLASS A -4 Q pl 7- <br /> HAZARDOUS <br /> HAZARDOUS WASTE CERTIFIED YES X NO WORK.CCMP.A7i3- 12-000IHb4 <br /> VIRE DIS'RICT PE%%IT 0 <br /> BOARD OF EQUALIZATION a <br /> TANK ID A TANK SIZE CHEM LCALS TO HE STORED PROPOSED IIISTALLATSGN <br /> 39- I DATE <br /> 39- <br /> 39- <br /> 39- �r <br /> 39- <br /> 39- <br /> 1 <br /> APPROVED APPRO 0 WITH CONDITLON(S) DISAPPROVED <br /> /1�C EE AT CHMENT WITH CONDITIONS) <br /> PLAN REVIEWERS NAMEIE'ryTry�� d � IL/✓/A - T�B-1B}}T}y DATE <br /> { { { { { { { {t al all{lil����� {{ {{ { {{ <br /> PLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> .N JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: wL CERTIFY THAT IN <br /> E PERFORMANCE OF THE 9ARAT !OR 'ANTCY THIS A•RMIT IS ISSUED, I SHALL AVT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> BJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR.WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> MPENSATION LAWS OF CALIFOR <br /> NI <br /> A." <br /> PLICANT'S SIGNATURE: (tiG'-'^�'^d�^ LJ�-"-`> TITLE 5RFC71Cc0ALV llA 0R_ DATE -11-20OL-3 <br /> ate the responsible party to be bi LLed for additional PKS•EHO staff time expended beyond the a hazer minimsn fnsta'.tatior, <br /> nt. The party must acknowledge this responsibitity for the additional, billing by signature and date below. <br /> Qf. CRAIG 10L . <br /> r — <br /> ng Address ill Lj <br /> hone Nuo/b1er� �pU F 'e 1/1� ars <br /> -src Ll.'M,b.-ti �L I,IM.�J��C Date <br /> 008 (Rev 12/13/95, UST ReB's May 5, 1994) <br /> 4 <br /> 9 -d .'102id VIVZV:E3 OOOZ-©L-L <br />