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• <br />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 # O PROJECT CONTACT & TELEPHONE # Tt�rC-,(% <br />F FACILITY NAME,L(_- 'a PHONE #(2 Yit� —Z 'Y4 <br />A <br />C ADDRESS <br />I <br />L CROSS STREET c 7Z 9 <br />I <br />T OWNER/OPERATOR PHONE # <br />Y S lit`[ al _ 10 6;?7 5 '' 631 So' <br />C CONTRACTOR NAME Pm�- C, P"ONEAi2oAT7 <br />}04 <br />0 <br />N CONTRACTOR ADDRESS,", IGH LIVL� �. CA LIC # � CLASS <br />T <br />R HAZARDOUS WASTE CERTIFIED YES_ NO WORK.COMP.# <br />A <br />C FIRE DISTRICT PERMIT # <br />T <br />0 BOARD OF EQUALIZATION # H y H a -M, _ ()l 01 <br />R <br />TANK ID # _ TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- / l , (aG' C u - Re" • w y'Z DATE C/ <br />T 39- lx'"1yen UX,6 LL'*�OL—r— <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L _ APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <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, 1 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 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." 7 <br />`�. <br />APPLICANT'S SIGNATURE: TITLE PIJ11 ' ' /�""DAT <br />Indicate the responsime Party TO De DllleG Tor aMIXIOnal Vnb-tnU SLaTT n11111 CAPUFRACLA unrvnu UM O nwl <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name °�J tial `jex 2. 0l & <br />Mailing Address �� �' �XUMa 1 ��1'k 1 �U ► r � (CJI n-� L C iq L% S <br />Day Phone Number e <br />Signature Date <br />EH 23 008 (Rev 1/7/92) WP <br />G1 <br />