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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 END OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />EPA SITE # <br />F FACILITY NAME <br />A <br />C ADDRESS <br />I <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR <br />Y <br />C CONTRACTOR NAME ' <br />0 <br />N CONTRACTOR ADDRESS ®6 <br />T <br />R HAZARDOUS WASTE CERTIFIED <br />A <br />C FIRE DISTRICT <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />I 11111111111111111111111111111 <br />TANK ID # <br />39- <br />T 39- z <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P 111111111111111111111111111111 <br />L <br />A <br />DO NOT WRITE IN ANY SHADED AREAS: <br />PROJECT CONTACT & TELEPHONE # <br />i ✓ 1 <br />N-ENW, M74 <br />rlrl <br />CA LIC # <br />GALS TO BE <br />APPROVED WITH CONDITION(S) <br />ATTACHMENT WITH CONDITIONS) <br />PHONE # <br />PHONE # <br />PHONE # ®_.( f <br />9� CLASS <br />WORK.COMP.# <br />PERMIT # <br />_ DISAPPROVED <br />Tj <br />PROPOSED INSTALLATION <br />DATE -ZSR 6 <br />N PLAN REVIEWERS NAME <br />DATE <br />liiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiI M1 11 1 1 111111 II <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." <br />APPLICANT'S SIGNATURE: lc�llV� TITLE �Vl P I DATE 7-94 <br />Indicate the responsible party to be billed for additional PHS-EHO staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this resp/-o�nsibility for the additional billing by signature and date below. <br />Name (� L i Gu n 1 S LENS 7 L t� <br />CIS I <br />Mai l i ng Address Non ®L'/ 0'aft �''% � titi%(J !/I `° _ te, �►' ° � 3 & U <br />Day Phone Numberu= <br />'11 c <br />Signature a AAA <br />EH 23 008 (Rev 12/13/95, U <br />'s May 5, 1994) <br />4 <br />Date 4 C — ( 6 <br />