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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOR THE CALENDAR YEAR.IN WHICH IT HAS BEEN <br /> ISSUED. A PERR1rr MAY BE EXTENDED INTO THE NEXT CALEI4DAR YEAR IFA LETTER IS SENT TO EHD REOUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALEN DAR YEAR. A ONE TIME ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER <br /> PROJECT CONTACT; CON <br /> � <br /> TACT PHONE# <br /> � t?sS�s� �© <br /> FACILITY NAM FACILITY PHONE# <br /> �. � P�, I,1e. ���� � 2 -�3b-33� I <br /> FACILITY ADDRESS: CROSS STREET: <br /> 55USCA � <br /> OWNERIOPERATOR: PHONE: <br /> 74110 <br /> CONTRACTOR NAME: PHONE: <br /> Wes, 2 <br /> CONTRACTOR ADDRESS; CA LICENSE# <br /> ©3 1013 D � C) Z <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> _YES NO R b , —1-% <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> i <br /> TANK ID# I TANK SIZE CHEMICAL STORED i PROPOSED INSTALL DATE <br /> 1 10 i %AL <br /> I i <br /> I I _ <br /> APPROVED APPROVED WITH CONDITIONSi <br /> DISAPPROVED , <br /> (see attachments) <br /> PLAN REVIEWER'S NAME t✓ L 1 DATE <br /> APPLICANT MUST PERFORM ALL WORK IN AC RDANCE WITH SAN JOA 6U 1 COUNTY O DINANCE4STLAVAS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS <br /> SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED;I SHALL EMP O P RSONS SUBJ CT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> Applicant's Signature <br /> Title /�� Date <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 6-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date <br /> �below. <br /> p <br /> Name ��c�a r A)�n y1, Date ` p� d�-l0 <br /> Mailing Address <br /> Signature Daytime Phone 97-C <br />