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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 BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO PHS-EHD REQUESTING THIS EXTENSION THIRTY DAYS <br />PRIOR TO THE ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended 0eyona the d hour minimum insiaLLoL, via <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name —P�FrLm' 62A F 16,NA <br />Mailing Address 13 <br />=1 W'��� LN <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev <br />4 <br />Date <br />EPA SITE ;*�� �5-S <br />PROJECT CONTACT & TELEPHONE x M 1 �( ( tc� 6^ LZ,� <br />F <br />FACILITY NAMEFLl� �iil(Fn}('f�.� (NG PHONE * 1,, 73 -^t <br />A <br />C I <br />ADDRESS '' � "� k:'%i/�t' 141 L� L�r7t c 0*1 <br />I <br />L <br />J <br />CROSS STREET ('�� L k , <br />I <br />T <br />PHONE <br />OWNER/OPERATOR <br />C <br />CONTRACTOR NAME AA(, ��l"a i�sr/ti `l�v�' (/V I PHONE #�q J :� <br />0 <br />N <br />CONTRACTOR ADDRESS p���C f O Z <br />CA LIC ��� �'� CLASS` <br />R <br />HAZARDOUS WASTE CERTIFIED YES_ NO WORK. COMP.;* L4N 6r((051 -3L36 <br />A <br />C <br />—„ PERMIT <br />FIRE DISTRICT L -,00((c.1 (2�*-- <br />0 <br />BOARD OF EQUALIZATION 9 <br />llilllllll11111lilllllll <br />TANK ID TANK SIZE C?Ai.LON S CHEMICALS TO BE STOR D PROPOSED INSTALLATIONV <br />TANK <br />got `, t1� OCY dA)LE'�iF\0-910 6014 0j 5PO4"j60AT'e (498 I <br />T <br />39- p`, <br />39- © 7 TO <br />A <br />39-I <br />u <br />39- <br />K <br />39- <br />39 - <br />Illi <br />P <br />L <br />APPROVED X APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />_ <br />�jI ]�(Ss'c�" ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME �iF��J'r~ J'/1/f 1 DATE 7 <br />1111111111111111lII111 illiiiiilll! Ill�llllllilillllilllllllll Iill!lIIIIlillllilllllll111111111! 11111111 111111111111111! <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 />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFO A." <br />r` �'r� • Pte?" <br />,�k ,, <br />m IJ (Oft' [ WAL7-0/• DATE' <br />APPLICANT'S <br />SIGNATURE TITLE <br />j <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended 0eyona the d hour minimum insiaLLoL, via <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name —P�FrLm' 62A F 16,NA <br />Mailing Address 13 <br />=1 W'��� LN <br />Day Phone Number <br />Signature <br />EH 23 008 (Rev <br />4 <br />Date <br />