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IN 1� A- <br /> 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 PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IFA LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR A ONE TIME ONE YEAR EXTENSION MAY BE GRANTED BY EHD U PON RECEIPT OF THIS LETTER <br /> PROJECT CONTACT: CONTACT PHONE# <br /> —tlinr ��ZG 0%1�- S �31-- 1 q10 <br /> FACILITY NAMEJ FACILITY PHONE# <br /> FACILITY ADDRESS: CROSS STREET: <br /> Tat C v �iJ n� <br /> OWNERIOPERATOR: PHONE: <br /> CONTRACTOR NAME: PHONE: <br /> We,vxt A irm� (6 t�4 90 -,,1 Z, 10 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> p 1 V\L3 _ ' ,23,? � (S C) 2 <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> _YES NO Q ,rl 19 q2 - 13 <br /> FIRE DISTRICT: PERMIT# <br /> I <br /> { <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> i <br /> I <br /> I <br /> APPROVED APPROVED WITH CONDITIONS DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN AC RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <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 TC <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOWING "I CERTIFY THAT IN THE PERFORMIANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED, I SHALL E[vIPQ0Y PERSONS SUBJ CT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> C -6 �L I L <br /> Applicant's Signature <br /> Title ew Date W2Sr 1 3 <br /> I <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the B-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> NameGdC�QI� K��LCt�) 1 Date _ <br /> Mailing Address <br /> Signature Daytime Phone QZL LI'L ci)n <br />