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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 />DO NOT WRITE IN ANY SHADED AREAS. <br />Indicate the responsible party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this rAsponsibility for the additional billing by signature and date below. <br />Day Phone Number ( :zt & ) 71,311— <br />Date <br />1,3 <br />2 <br />Date <br />EPA SITE # CIA1 <br />PROJECT CONTACT & TELEPHONE # <br />F <br />A <br />FACILITY NAME <br />la <br />PHONE # <br />C <br />ADDRESS <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/OPERATOR 19 <br />PHONE # <br />Y <br />C� <br />C <br />CONTRACTOR NAME <br />PHONE # <br />0 <br />N <br />T <br />CONTRACTOR ADDRESS <br />CA LIC # CLASS <br />R <br />HAZARDOUS WASTE CERTIFIED <br />YES NO WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />BOARD OF EQUALIZATION # <br />R <br />Illllli!l111I11lllliltllll!!1t <br />TANK ID # <br />TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39- <br />DATE <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />l111 <br />T <br />L <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />E TTACHMENT WITH CONDITIONS) <br />III <br />N <br />PLAN REVIEWERS NA <br />111l1111it1111lI1111 ! 11 ! <br />DATE r7 <br />I 1 !11 1 I 1 111 II 11 1111l11l1111 1 llllltllllll 1 ! 1 Ilil1111i1 !I!!1 <br />APPLICANT MUST PERFORM ALL WORK <br />IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR <br />WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION <br />LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE <br />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: <br />TITLE DATE ✓ _ <br />Indicate the responsible party to be billed for additional PHS -END staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this rAsponsibility for the additional billing by signature and date below. <br />Day Phone Number ( :zt & ) 71,311— <br />Date <br />1,3 <br />2 <br />Date <br />