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04/18/2000 10:30 20946834 FIFTH FLOOR PAGE 05 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br />ENVIRONMENTAL HEALTH DIVISION MAY <br />APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION P'R IST <br />HEALTH <br />C1 jV,rkj1'4 3 \L <br />THE APPLICATION FOR INSTALLATION OF UNDERGROUNiD STORAGE TANKS IS ONLY VALID FOR THE CAL ENDAFFIZV WMWli9`"61S BEEN ISS'JEC, <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 AE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # PROJECT CONTACT 6 TELEPHONE�Dz# ! _ <br />F FACILITY NAME ' PHONE # <br />A <br />C ADDRESSp <br />1 q <br />L CROSS STREET <br />T OWNER/OPERATOR PHO # q <br />Y -� !tom <br />C CONTRACTOR NAME PHONE s [? <br />N CONTRACTOR ADDRESSpD CA LtC # CLASS <br />T <br />R HAZARDOUS PASTE CERTIFIED YES NO WORX.COMP.A <br />I <br />A <br />C FIRE DISTRICT PERMIT tY <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />TANX <br />tlltlrtltt1 ttttttt�tttu <br />TANK 10 # TANK SIZE CNEMjCALS ":0 9E STORED PROPOSED INSTALLATION <br />39- 20.00c> ONLEAO CTA,g GATE slsy/oo <br />T 39• 1 or 000 ,\ e6 y z <br />A 39, 10,000co iBseL Os <br />N 39• <br />K 39• <br />39• <br />Nll ffffff=11111 ITRTIII 11111111111111111111111111111 MTMTflT <br />P <br />L APPROVED _ APPROVED WITH CONOTTION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITd CONDITIONS) <br />N PLAN REVIEWERS NAME BATE <br />11lfttlllltlttllllttlllllllllllt!!I II llltlfltllllllftltflllfl! !tl ttlll t <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PU®LIC HEALTH SERVICES, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; 111 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR Wt ICH 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." CCNTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WKICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: V TITLE P/LO%G a- AW4&4ATE 2 Uv <br />Indicate the responsible party to be bitted for additional PHS -END staff time expended beyond the a ncur miniman Instattaziw <br />paren <br />t. <br />The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name Yllt�T�'Csa Izi <br />Mailing Address 41z?— <br />Day <br />/ <br />Day Phone Nvnter. <br />SignatUr <br />EH 23 00 <br />UST Reg'S May 5, T <br />d <br />C -v4 `'62/ <br />Date <br />