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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANK$ ARE ONLY VALID FOR THE CALENDAR YEAR IN WHICH It HAS SEEN ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IX 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 QY PHS-END UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> PADDRES$ <br /> SITE if� �! PROJECT CONTACT t TELEPHONE N <br /> V�Ncr r Slo <br /> FILITY NAME <br /> A PHONE k r <br /> C <br /> I <br /> L CROSS STREET -� <br /> 1 <br /> T OWNER/OPERATOR <br /> Y Q& <br /> C PHONE E <br /> C CONTRACTOR NAME <br /> JO) G1� . <br /> 0 PHONE t Q <br /> N CONTRACTOR ADDRESS ? c r EC~ u c 2 b s5 <br /> T Li <br /> R HAZARDOUS WASTE CERTIFIED yE NO <br /> A WORK.COMP.# &--, _ <br /> C FIRE DISTRICT �46CJ <br /> TFiizisPERMIT N <br /> R BOARD OF EQUALIZATION 0 y 0-10 I <br /> TlfKllol�li!ltUlli! <br /> 39- <br /> TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTIfi T N <br /> T 39 ? DATE <br /> A 39- LEA <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> fill III <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME <br /> liliili!lllllll!llil DATE <br /> lIII>I!Immuffffffumu <br /> APPLICANT MUST PERFORM ALI. WORK IN ACCORDANCE WITH SAH JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br /> SAN JOAOtIIN COUNTY PUBLIC HEALTH SERVICES. OWNAND RULES AND REGULATIONS Of <br /> ER OR LICENSED A499TIS SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT 1N <br /> THE PERFORMANCE OF THE W094 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 WOMKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> �y cc Tc- <br /> APPLICANT'S SIGNATURE: TITLE rp�' <br /> IdU+—DATE 14 j S' <br /> Indicate the rasp"jbte party to be bitLed for additional PNS-EMO staff time expanded beyond the 8 hour minimum instattation <br /> The pbrty muat ackr*wtedpe this responsibi[lty for the additional biLLirq by atlgnaturt and date below. ym <br /> fi t' <br /> Ham! <br /> Mailing Address x <br /> ILI <br /> Day Phone Nmter <br /> Signature <br /> Dote <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br /> .-.� . - i � . i f� Tr i L TI-. •�n Lir T lL.i ,tel i� <br />