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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 PNS-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 /> EPA SITE # PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME S PHONE # <br /> A P <br /> C ADDRESS <br /> I ` <br /> L CROSS STREET (�? <br /> I <br /> T OWNER/OPERATOR PHONE * _ <br /> Y / � ` � -- 1� / '� <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LiC # CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> 111111111111111111111111111111 <br /> _ TANK ID # —TUX SIZE -'"1� CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39 lJ 5 KJ LSI r i�, DATE <br /> T 39- <br /> A 39- _ <br /> N 39- i <br /> K 39- <br /> 39- <br /> 39- <br /> P IIII <br /> L APPROVED APPROVED WITH CONDITION(S) - DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> I 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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: •1 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 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 SIGNATURE: TITLE DATE <br /> EH 23 000 (Rev 1/7/92) WP Page 3 <br /> 3 <br />