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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 # L q p G}$2 D IE�,-1 4 3 PROJECT CONTACT & TELEPHONE # �� �j 1 Ir�t r� Lq i b) Lo 3 5- ZL Li y <br /> F FACILITY NAME ��v�� g 4.,. PHONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y On;1n) a"1 42 ( 918) 96►-I --792Z <br /> C CONTRACTOR NAMEvv� � .��j y� ��-}�� PHONE # <br /> 0 1 - <br /> N CONTRACTOR ADDRESS CA LIC # !'�c) d--� CLASS A, <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES k NO <br /> A <br /> C FIRE DISTRICT �� S�� -� PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> TANK <br /> TANK ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 1 Z , Q[X� �,c�)Inr� oL►�.sc=l �-yt .120 DATE <br /> T 39- i5.1 00(� 'r 4 g'7 0C— a.r.rz 34n 1v .vie—1 0 <br /> A 39- ratio a av4eca -F;7 i 1ej C4"'Es <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P <br /> L _ APPROVED H=! APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE AT \ ENT WITH CONDITIONS) DATE -Z6 <br /> N PLAN REVIEWERS NAME <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 COMPENSATION 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." ^ �� r ' <br /> APPLICANT'S SIGNATURE: l Iv TITLEC-�K9'K DATE I0-10—iS <br /> Indicate the responsible party to be billed for additional PNS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name _ 4- S <br /> Mailing Address �.A.uM✓i t E:3 2,0 Lv 1�3nC.�,o C �d G� Cc r.`1 1-I Z <br /> Day Phone Number L,) 1v3 Zr-1 '--1 <br /> Signature Llel- cam- p Date <br /> EH 23 008 (Rev 1/7/92) WP / — �[ �0 <br /> 3 <br />