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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 /> EPA SITE #/-L ���/� PROJECT CONTACT & TELEPHONE # �iNCi✓ oIL33 <br /> L �IG n� 7 <br /> F FACILITY NAME Y 1 �•v - I PHONE # C ,I _ 1 '/ <br /> A <br /> C ADDRESS : ' S <br /> 1 s4J Jof)c4u Coy <br /> L CROSS STREET q <br /> I 1 <br /> T OWNER/OPERATOR �-p- PHONE # <br /> Y 5 LL, Ol(- C ��( I1 -5 <br /> CCONTRACTOR NAME <br /> O Q 1 n /CS PHONE E))0, <br /> O <br /> T CONTRACTOR ADDRESS�7 VCRP — COU U r7o CA LIC # Z 6C ASS <br /> _I 3 <br /> R HAZARDOUS WASTE CERTIFIED YE jN0 WORK. 5 7 _ <br /> A K7 <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # I O <br /> R <br /> T .1D # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTAL ATION <br /> 39 K ,(- RE�./f 12 Uti l� Ot, C> xI IN( DATE c <br /> T 39- i S� rsf�1_u>►1 P UMI UNI VNLC-+nt O - U < <br /> A 39- <br /> N 39-- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> �111111111111 1111 �������������� <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> �y C-0W IA-C-TDI <br /> APPLICANT'S SIGNATURE: <br /> - 1� <br /> TITLE ;c t r-t'w�ci�.z1 DATE <br /> Indicate the responsible 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 �y <br /> Mailing Address _ L C > �►f j <br /> U 3C) �1'x 5-CM, <br /> Day Phone Number S,l <br /> Signature I C A ULA `{ p <br /> Date vV <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />