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12/09/2003 15:09 9252836876 DESIGNERS COLLEC'TTVE PAGE 03 <br /> 10/30/2003 11:41 20946834 FIFTH FLOOR PAGE 04 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLIGATIQN FOR INSTALI.AT70N OF UNDERGROUND sTORA^E TANK$Is ONLY VALtO FOR THE CAI,GNDAR YF,AR IN WHICH IT HAS BEAN <br /> MSUED. A PERMIT MAY BE EXMDED INTO THE NEXT GALENDAR YEAR IF A I.ETTER IS SENT TO EHO REQUESTING TFM$EXTENSION THIRTY <br /> DAYS PRIOR TO THE PND OF TNS CALENDAR YEAR A ONE TIME,ONE YEAR.EXTENSt014 MAY BE GRANTED BY EMM;UPON RECEIPT OF THIS <br /> LL-1 <br /> PROJECT CONTACT: CCEN'I'ACT FIONE <br /> FACILITY NAME: {�G rjI s 0` FACILM PRONE# <br /> FACILITY ADDRESS: l .{ CROSS STREET": ,fi <br /> M <br /> OWNER/OPERATOR: .r a � yrs -*� PHONE: <br /> CONTRACTOR NAME: T PHONE- <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> EAZARDOUS WASTE CERTHICATE: 'Y'ES NO WORKERS COMP# <br /> FIRE DISTRICT: 646 Y <br /> PERNIIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE MICA.L STORED PROPOSED INSTALL DATE <br /> s civ r <br /> Z- <br /> 0 <br /> 0 APPROVED 0 APPROVED WITI1 CONDITIONS 0 DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE. <br /> APPLICANT MUST PERFORM AJ-L WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL FIEALTH DEPARTMENT.OWNER OR LIQI NSED AGENT'S <br /> SIGNA'T'URE.CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH T)VS <br /> PERMIT IS ISSUED.,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUSTEC'T TO wOKKER'S <br /> COMPENSA71ION LAWS OF CALIFORNIA."CONTRACTOR'S FLING OR SUBCONTR.4,CTING SIGNATURE CERTIFIES THE <br /> FOLLOWING"I CERTIFY THAT IN TSI£PERFORMANCE OF THE WORK FOR WHICH THIS PMNfII•IS ISSUED,I SMALL. <br /> EMPLOY PMONS SUBJECT TO WORKUR'S COMPENSATION L OF C IFORNIA 9 <br /> APPLICANT'S SIGNATURE <br /> TITLE DATEc1- <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour <br /> minimum installation paymeait.The party must acknowledge this responsibility for the additional billing <br /> by signator and date below. <br /> Date <br /> Mailing Address I// Y�✓�p ,� '�//D �r r�i��+�, lw fY-~y <br /> � Daytime Phone �15=9z-7. <br /> Signatuzv *� �9 <br /> - s - <br />