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04/1012000 10:30 2094683433 FIFTH FLOOR PAGE 05 <br />-4 ?4�'`` <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br />ENVIRONMENTAL HEALTH DIVISION MAY 9 <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PER J HEALTH <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS 1S ONLY VALID FOR THE CALENDAFPUAA1/%%M9E1 BEEN ISSUEC, <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 />EPA SITE q PROJECT CONTACT B TELEPHONE # _ <br />F FACILITY NAME VjStal /6,5 ' ru PHONE # <br />A <br />C ADDRESS u�1t7 <br />1 <br />L CROSS STREET <br />— <br />T OWNERlOPERATOR PHO N <br />Y t - 9! <br />C CONTRACTOR NAME PHONE #i <br />0 'i <br />N CONTRACTOR ADDRESS p0 ` CA LIC # CLASS <br />I <br />R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# <br />A <br />C FIRE DISTIL CT PERMIT M <br />T <br />0 BOARD OF EQUALIZATION 0 <br />R <br />llllittllllillitlllttll11111t! � <br />TANK IC # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br />39• Zo 00b UNLEAp GA DATE 51sVlee <br />T 39- I01% It y <br />A 39• 1 0y00 _ iESEL _ �sY/aes <br />N 39- <br />K 39- <br />39 <br />I! I I tiTiTTIlTITT1TITtTTtT <br />P <br />L APPROVED _ APPROVED WITH CONDITION($) Y DISAPPROVED <br />A (SEE ATTACHMENT W:TH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />IIIIIIII IIIIIIIIIIIII 1111111111111111111111111111 liiiiiiiiiiiiiiiiiiiiiliffffrffffiffmiIIII III I III I III 111t11111111111 <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 VMICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." � � ��yp <br />APPLICANT'S SIGNATURE: �''�f"�/' Ti ''r TITLE PIjrL�P1 4' yJ r 1//�Ir/[�4ATE �2O <br />Indicate the responsible party to be bitted for additional PNS-EHD staff time expended beyond the 3 hour minimum Installation <br />paymenit.. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name Vr�,��.C�ll'?.A-1i.�1 <br />Mai L ing Address 1 Z? F(�8 1.+07 A: Qt% zE Ptu L'e- . ✓Git1J l `"`�. � 2% j — <br />Day Phone N <br />Signature <br />EH 23 008 (Rev 1 /95, UST Reg'S <br />4 <br />Date 6 <br />