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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 -END 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 # � (t3�5 l7 PROJECT CONTACT & TELEPHONE # LVIA �7 <br />F FACILITY NAME zn©CA/ �) & PHONE # � gw73�_• •73( <br />A / c-"O�'�� <br />C ADDRESS 7Ql /far L4J)� ✓1 <br />I <br />LCROSS STREET �/ s <br />1 �^ <br />T OWNER/OPERATOR (, PHONE # <br />Y Ixv/�ibckt�s deo L�nac�l X18 8 ? <br />C CONTRACTOR NAME /""fQ✓�tll� f �h �r��� PHONE # 17/4_ QA — B <br />N CONTRACTOR ADDRESS /T/ ! CA LIC # L�`787 CLASS <br />R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br />A <br />C FIRE DISTRICT <br />R. _S4, ✓% PERMIT I# <br />T <br />0 BOARD OF EQUALIZATION # <br />111111111111111111111111111 11 <br />TANK ID # TANK SIZE CHEMICALS TO BE STORED P, POSED INSTALLATION <br />39_ � DATE <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- ` <br />39- <br />P 111111111111111111111111111111 Illliiilllllili111111I1111111I1I 111111111111l1I11111EN1��1�1� ��I� 1mIIIIIIIIIIIIIIII <br />L _ APPROV PPROVED WITH CONDITIONS) _ DlspERNWERVICES <br />A (SEE ATT NT WITH CONDITIONS) .� <br />N PLAN REVIEWERS NAME DATE lI <br />11111111111111111111 lT1T 111111 <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: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COIRENSATION 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 C L " <br />APPLICANT'S SIGNATURE: TITLE t 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 acknowledge this sponsibility for the additional billing by signature and date below. <br />�i 4 <br />Name +R s✓ <br />Mailing Add s Mqo 1506041-6eo 1i[(J aAe)ic 6wdooL 09 95 74a <br />Day Phone Nr // <br />Signature t Date [c`w <br />/_ ,� .ems- �-�=�i2"`^ �,^^�=� (.0 u� r ccri• �1�-•.��/v�-� - <br />EH 23 008 (Rev 1/7/92) WP /' <br />