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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <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 <br />ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO 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 EHD UPON RECEIPT OF THIS LETTER. <br />PROJECT CONTACT: / CONTA <br />CT: <br />Ohoa <br />CONTACT PHONE # <br />FACI T��Y(( /N//}}�AMEr% 41 C % <br />11 dild iik�., <br />FACILITY PHONE#lj <br />FACILITY AD RESS: <br />7 , a !el �� ' I ���J�� <br />CROSS STREET: <br />creh k o d <br />OW ER/O ERATOR: <br />,pct, So i(c <br />PHONE: <br />' ��t - � <br />CONTRACTOR NAME: <br />() /Li � <br />PHONE: <br />A I. LI 1 <br />( <br />CONTR�A-CjT�OR ADDRESS: <br />CA LICENSE # <br />6 HAL <br />HAZARDOUS WA CERTIFICATE: <br />YES NO <br />WORKERS COMP # <br />`i � � _0 Y <br />FIRE DISTRICT: -}- PERMIT # <br />t <br />BOARD OF EQUALIZATION # <br />TANK ID # TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br />❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br />(see attachments) <br />PLAN REVIEWER'S NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, <br />RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br />SIGNATURE CERTIFIES THE FOLLOWING" I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED., I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />CERTIFIES THE FOLLO G "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br />ISSUED, I SHALL EMPLOY PERSONS.SUBJEQTTO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />Applicant's Ip attire <br />Title <br />Indicate the res ons <br />ible <br />paymen The e party mus <br />Nam <br />Mailin Ad ess <br />Signature <br />a <br />Date <br />party to be billed fdf additional EHD staff time expended beyond the 8 -hour minimum installation <br />acknowledge this responsibility for the additional billing by signature and date below. <br />l�lwi)7 � a A(1), 1_`1 - ['�\, . oath/al__Z�/ <br />Revised 07/22/10 3 <br />Daytime Phone <br />