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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 ISSUED. <br /> A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT b TELEPHONE <br /> F FACILITY NAME PHONE # p 9 <br /> A UNITED V <br /> ADDRESS 440 CHARTER WAY <br /> CROSS STREET <br /> I LINCOLN <br /> T OWNER/OPERATOR PHONE # <br /> Y JODHA GILL 833- 6jya, <br /> C CONTRACTOR NAME F I L PHONE # <br /> 0 <br /> N I CONTRACTOR ADDRESS CA LIC # I CLASS <br /> T 3633 spApogT BT.vT) — <br /> R HAZARDOUS WASTE CERTIFIED YES�1� NO WORK.CCMP.» <br /> A , <br /> C I FIRE DISTRICT PERMIT » <br /> T <br /> 0 BOARD OF EQUALIZATION <br /> R <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- 1; ." J;' s� <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L APPRO /X. APPROVED WITH CONOITION(S) DISAPPROVED <br /> A (SE-E_ ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME J/ ;' DATE <br /> 11111111111111111111111111 IIIIII 111 Il lllililllll lllllillllll llllllllllllllll IIIIIIII111111111111 Iilllllllillll I I II I <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 /> "! CERTIFY THAT IN THE PERFORPAC OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNA. <br /> APPLICANT'S SIGNATURE: TITLE ✓� e c- &ATE <br /> Indicate the responsible party to be filled for additional PHS-EHO staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this rr�responsibility for the additional billing by signature and date below. <br /> Name �A1 <br /> Mailing Address d !` I TRA Cv /✓ 3 � <br /> Day Phone Number S - 6 ac7 <br /> Signature Date <br /> �-H 23 008 (Rev 12/13/95, UST Reg's May i, 1 ) - <br /> A <br /> Y <br />