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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> 32*1�.— 4 -rvlzGeak SUMP, bLl"-Pjg1-1StwiZ s� �5 AOA. -wwa—s-p►it <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE ANKS 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 FHS-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 PHS-EHD UPON RECEIPT-of.THIS:,mTTER� <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE S PROJECT CONTACT b TELEPHONE S_jC>jjA PAI`IZ-)o <br /> F FACILITY NAME k. 7`7-`' t93 PHONE S <br /> A <br /> C ADDRESS 32®Z y,,, �r<tr� <br /> 1 <br /> L CROSS STREET K.I1LL.� ��tVS <br /> I <br /> T OWNER/OPERATOR PHONE S <br /> Y , w�ra C� Ss8- 7. <br /> r _7Gi <br /> C CONTRACTOR NAME <br /> .;Mcs <br /> PHONE$�c�� ��.� aG <br /> D <br /> N CONTRACTOR ADDRESS 930Ama5 AVr !_Ut•. rrm, CA LIC S —5.7S CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YESNO Woax.Coau+:S ��C�Z"1Z-� <br /> A G,__,• <br /> C FIRE DISTRICT �7I0C.�-� F5ia '��- E t--�O� PERMIT NN <br /> T !� <br /> 0 BOARD OF EQUALIZATIONS -TY +4 ®036c Z <br /> R ' <br /> 1t1t11lt1ti11tiltl[liltlllttit 'n <br /> TANK ID S TANK SIZE CHEMICALS TO BE STOW PRCIPOSED INSTALLATION <br /> 39- GATE <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39 <br /> 39- <br /> 39- <br /> lltt <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (S £ ATTACHMENT WITH CONDITIONS) <br /> N PIAN REVIEWERS NAME. <br /> IIIttItlltttIII t(ttt tllit <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR-LICENSED AGEHT'S'SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A !BANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CCHPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATUIV ° i,.t — , D TITLE A&MA-1 ��,�(�SC0 DATE <br /> iicate the responsible party to be bi ed for additional PHS-EHD staff time expended beyond the 8 how. minimum instattation <br /> iment. The Party must aclamatedge this responsibitity for the additional bitting by signatUre•and date below. <br /> ;ting Address �J�--� IIC,k;Gya A504- ' ACZAi'''j9i_l ib CA 05-82S <br /> Phone Number <br /> Date 0/� <br /> 23 008 ( 13/95, UST Regis May/5, 1994$x_ 8. <br /> _, 4 <br />