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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 3E EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANT BY PHS-EHO UPON RECEIPT OF THIS LETTER. <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE ` PROJECT CONTACT & TELEPHONE 9 7 765-1(P&D <br /> F 1 FACILITY NAME �1��5 C G��N PHONE 4�'`7� t f'7� —019�7 <br /> A <br /> C ADDRESS g Qoo <br /> L CROSS STREET PoNCf D �'f�t/N ��6• n <br /> I <br /> YOWNER/OPERATOR lz'cr- i( n� l!J PHONE # i1 -7 -7 <br /> C CONTRACTOR NAME KEt4 w&J9 / l PHONE 2a9) <br /> N CONTRACTOR ADDRESS 3 22C, E. LAN[,S PR. M ca LIC ;*-1233GO CLASS py$3C40"i WM <br /> T <br /> R HAZARDOUS "WASTE CERTIFIED YES_/ NO WORK.CCMP.N ©0 i <br /> A <br /> C FIRE DISTRICT i ' , PERMIT T <br /> T <br /> 0 i 30ARD OF EQUALIZATION T <br /> R <br /> filtillltill111111Illillltlltl <br /> TANK ID K S E CHEMICALS TO 3E STORED PROPOSED INSTALLATION <br /> 39- 1 2%ae 11L t (I DATE <br /> T 39- 1 <br /> A 39- 17 lt9 44- <br /> N 39- <br /> K 39- 3L1 l� <br /> 39- <br /> 39- <br /> 1111111 fill III I I I I 1111111 1111111111111H1111111111 1111i iiiiiiiiiiiiiiiiiiiiiiiiiiiinTnTrnTri mannuninTrrff <br /> P <br /> L APP ED APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A = ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> tltlittllilliliilllllli ! !I 11 1 t !lttllttll 1 tt111 11 it i ! Illi tltttilllf til tlitl ! Ittl1 111 <br /> APPLICANT MUST PERFORM ALL WORKi ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH ERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR ICH 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 /> "I CERTIFY THAT IN THE PERFORMANCE OF THE 11ORK WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE r�.r� DATE <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The partymust aclmowiedlge this responsibility for the additional bitting by signature and date below. <br /> Name irt' i C-i�(— <br /> Mailing Address �V�v l C-4 <br /> Day Phone Number j2.0q) T (-7 d +f ) <br /> Signature Date <br /> EH 23 008 (Rev 12/13/95, UST Reg'6( May 5, <br /> 4 <br />