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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-EHO UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. Cj�j/0, <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # �- �� , Z % -�3v —76(i-7V <br /> F FACILITY NAME V71L � PHONE 7y3 -7 <br /> C ADDRESS ezf <br /> I <br /> L CROSS STREET <br /> Y ( OWNER/OPERATOR �� /) PHONE�t <br /> /17 <br /> C I CONTRACTOR NAME � 1�',�'Jl) ®/iOC� PHONE # !� .3 /~--723 <br /> 0 !n L• U <br /> N CONTRACTOR ADDRESS /v L �i J CA LIC # �G�d CLASS <br /> T (/ <br /> R I HAZARDOUS 'WASTE CERTIFIED YES NO WORK.COMP.;* _ <br /> A <br /> C FIRE DISTRICT PERMIT » <br /> T <br /> 0 30ARD OF EQUALIZATION <br /> IR { - <br /> 11111111 l 1 <br /> TANK 111111111 I i 111 <br /> � TANK ID » TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- 42y a, G DATE <br /> T 39, <br /> A 39- <br /> 39- <br /> 39- <br /> 9-39-39- �! �G v �7( s e <br /> i <br /> 39- <br /> 39- <br /> P <br /> 9- <br /> 39- <br /> P <br /> L APPRO PPROVED CONDITIONS) DISAPPROVED ) <br /> A TT ENT WITH CONDITIONS) /LJ <br /> N <br /> ,Inn , An <br /> F iIIIIIIIIIIIIIIIIIIII11IIIIIIII11111111111IfIIIIIIIII1111`111111t 11111111111111 <br /> ORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> HE PERFORMANCE OF THE WORK FOR WHICH THI RMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF L IA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE F WHICH THIS PERMIT IS ISSUED, I/HA,,1MPL11Y;PERSCNS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE• TITLE DATE 3- <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 nmust acknowledge this responsibility for the additional billing by signature and date below. <br /> Name �17 .'7�/��1 !✓�+ ----.._ <br /> Mailing Address '-/2 t-1-3 Ax1Z � ►"f' <br /> Ur'I � j i)���/ /sT <br /> Day Phone Number <br /> Signature Date <br /> EH 23 008 / /95, 6tT eg's May 5, 1994) <br /> 4 <br />