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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 -END 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 />00 NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE #CAL 000 O �S a�q PROJECT CONTACT & TELEPHONE # M 114E L Qi (o- -37-3-1 rog <br />F FACILITY NAME Z�UI� �j"r�� 7 (.> PHONE # �p.t �c�—/n ? -31 <br />A <br />C ADDRESS 1030 S C LIVE 4\rf STDLiLTON Cis' �75-7,05— <br />I <br />L CROSS STREET <br />T OWNER/OPERATOR PHONE # <br />C CONTRACTOR NAME PHONE # 9 (V— 3.7'5. <br />0 <br />N CONTRACTOR ADDRESS PO (iXjX l Das IBJ, SFC�u �{Sto�f I CA LIC # --� Z 8 CLASS <br />T <br />R HAZARDOUS WASTE CERTIFIED YES NO WORK. COMP .# w C Z 7 Tj p _ �O <br />A <br />C FIRE DISTRICT C X70 C I aN PERMIT # <br />0 BOARD OF EQUALIZATION # <br />R <br />1111111111 <br />TANK 111111111111111 <br />TANK !D # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- G` I IZ R22 Uh)Lf-AOeO (0"'r5 :Y"11 DATE 1gIS <br />T 39- r� V, h <br />A 39- <br />1 <br />N 39- { <br />K 39- <br />39- <br />39- <br />I111 <br />P <br />L _ APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />I1111111111U1111111 ii II I I i I I I II 1 111111 I IIII 111 I IIII 1 iil!! <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 PERFORMA E OF HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNI ." <br />APPLICANT'S SIGNATURE: TITLE DATE <br />Indicate the responsible party to be bitted for additional PHS-EHO staff time expended Oeyona the a nour minimum lm usL —..w� <br />payment. The party must acknowledge this responsibility for the additional bitting by signature and date below. <br />Name M I KE LEE r-rDZ Gwi t.— s -W M TS, /A6. <br />Mailing Address 4207 6N'kz(K ISF ST f;t6ykzk7 lo G6' 0/dflT8 <br />Day Phone, Q,�s (0) (PS -7— 35 -OD <br />Signature�� <br />EH 23 008 (Rev <br />UST Reg's May 5, 1994) <br />4 <br />Date Tia JIJ 1. I `g <br />