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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE #U� PROJECT CONTACT & TELEPHONE # �u D �- /� <br />F FACILITY NAME �nOCa/ �S � PHONE # c;M- 473 -- 7137 <br />C ADDRESS �'7D I pl..- nCA 0 <br />/ <br />L CROSS STREET S <br />I <br />T OWNER/OPERATOR r, /n / PHONE <br />Y <br />CCONTRACTOR NAME �/bh ��PHONEB3to <br />N CONTRACTOR ADDRESS /G f./ 9 � lnlw i �- Ste- CA LIC # � L�`787 CLASS <br />T '"''A/, <br />R HAZARDOUS WASTE CERTIFIED YES NG WORK.COMP.# <br />A <br />CFIRE DISTRICT, d.SJ.`c I PERMIT # <br />T <br />0 BOARD OF EQUALIZATION # -rV 9 Q -4-4- ocoQ <br />R <br />IAI1111111111l11111it1111l111111 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED P-QPOSED INSTALLATION <br />39- a DATE <br />39- I 1 <br />39- ki <br />N 39- <br />K 39- >inn <br />39- <br />39- <br />P 11111111111111lt11 11111 11111 Ittllil 1111 111 1��t`t` 11111 1 tllltllllllll111111111� 11 t,�l�!- �1� tt�.�lillilt7l-i1f1111 <br />L APPROVE ,/APPROVED WITH CONDITION(S) �EDISTewof� iERViCES <br />A r ( EE TTA WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />1111111111 11 <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 CD ENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN TH RMA OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF L " <br />APPLICANT'S SIGNATURE: TITLEEY� DATE <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowtedge thisresponsibility for the additional billing by signature and date below. <br />Mailing AddMscDwo <br />Day Phone <br />Signature <br />EH 23 008 (Rev 1/7/92) WP <br />_/) /Date <br />