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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-EHO UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # G%(, QpI ,/jb 224, PROJECT CONTACT & TELEPHONE # C*A& !SC40f09 - FL (L - IDI .7,4s,1i60 <br />F FACILITY NAME C PuizA q- g64b PHONE # Z01- 01;:S(- 21� <br />A <br />C ADDRESS 4400 WA -mm -co ¢fj_ <br />1 <br />L CROSS STREET f I GG 01.1 9�0. <br />I <br />YOWN ERATOR ^ I ,& O /MM G*S;,tD PHONE # &Q _ el 3i - 218E <br />C CONTRACTOR NAME i.1 - a (I,,� V <br />0 Yv �sv <br />N CONTRACTOR ADDRESS pO�J14q� 9524{ CA LIC #_.? <br />T <br />R HAZARDOUS WASTE CERTIFIED YES NO 3 G <br />A <br />C FIRE DISTRICT Ih1A�LoO MVj16A•�A. <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />Illllilllllilil111111111111111 <br />TANK ID # <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39 - <br />III <br />TANK SIZE CHEMICALS TO BE <br />fog 000 I ep-Le.,g L <br />!6j aQb 4GUP2-rPM� <br />PHONE # tjaD% - 5q7 _ g 3j0 <br />525e= I CLASS A * ► Co, 44a7, <br />WORK.COMP.# w 9 T C2 jA,000 1 <br />PERMIT # <br />PROPOSED INSTALLATION <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A �a� E AT HM T WI H CONDITIONS) <br />N <br />PLAN REVIEWERS NAME �J� of s M <br />DATE <br />-� <br />dtIIlllillll1III 111111111 11 I11 liliilliil 1 ' 1111 IRII111111111111111111111111I11i11111111111111111111111111 <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." �Q p <br />APPLICANT'S SIGNATURE:. j, � i.! . 6�1�t. TITLE i IPAJ MC'�CZ• DATE � f `7 <br />Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name �'1-'� �. . . _ C.C� • JPUA4(7- 065 -J - <br />Mailing Address '!:'/"_ _ Co00�- .N �.pl.1 I CA <br />Day Phone Number 5/0 <br />Signature_ A/i Date 10/9 LAO 7 <br />EH 23 008 (Rev 12113/95, UST Reg's May 51 1994y,i���ti P64 S t"! p <br />fl�Jrr�� l it l(.0 <br />IL" <br />©2 �� r'SS �`,� a C��, �u e�� 54 7--- alk <br />0-&t 10 <br />