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R <br /> 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 1S SENT TO PHS-EHO REQUESTING THIS EXTENSION THIRTY DAYS <br /> PRIOR TO THE ENO OF THE CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> 00 NOT WRITE IN ANY SHADED AREAS. <br /> PROJECT CONTACT & TELEPHONE # .,D1 y p I <br /> EPA SITE # <br /> ^ y� A PHONE # <br /> F FACILITY NAME V��VV-DtA �i r `' <br /> A I' ®5 V+11TE_ U E wtfT� <br /> IADO ESS �rj.-2j`' <br /> L CROSS STREET � - <br /> 1 )PHONE # /�,� G1(j 0U <br /> T OWNER/OPERATOR &0 (. J �I <br /> Y PHONE # � <br /> C CONTRACTOR NAME T-o � D <br /> �J � <br /> 0 CA LIC # CLASS <br /> N CONTRACTOR ADDRESS <br /> TYES NO WORK.COMP.# <br /> R HAZARDOUS WASTE CERTIFIED <br /> PERMIT # <br /> A <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> i <br /> R <br /> {{{{{I{II{{{{{{{{{{{{{{{{{{{{ <br /> CHEMICALS TO TANK SIZE BE STORED PROPOSED INSTALLATION <br /> TANK I0 # 2b ate , b� �,��_ DATE , <br /> 39- <br /> T 39- p tl -�• <br /> A 39- <br /> i <br /> N 39-_x_ j <br /> K 39- <br /> 39- <br /> 39- <br /> 9-39-39- Muffimmmuffummm <br /> P 1111 APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) <br /> DATE <br /> A <br /> N PLAN REVIEWERS NAME <br /> IIIIIIIIIIIIII III III <br /> EGULATIONS <br /> APPLICANT MUST PERFORM ALL <br /> LHWORK IN ACCORDANCE WITH <br /> RVICES. OWNER OSAN <br /> JOAQUINACOUNTYORDI ATURESCERTIFiESATHE FODLLOUI!!G-LES AN"IRCERTIFY THAT rIN <br /> SAN JOAQUIN COUNTY NOT <br /> OME <br /> THE PERFORMANCE OF THEM WORK <br /> F IONWLAWS OFICALIFORNIAS PERMIT S"ISCONTTRACTORA'SLHIRINGMOROSUBCONTRACOTINGNSIGNATURESUCH A ACERTIFIESNNER AS OTHECFOLLOWING: I <br /> SUBJECT TO WORKER'S CO 1 <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER' <br /> COMPENSATION LAWS Of CALIFORNIA." I <br /> TITLE'�2a?� tnA�JAGc: DATES 25 <br /> APPLICANT'S SIGNATURE: <br /> Indicate the ressponsible part to acknowledbe ge thiseresponsfor for dibilityaforHtheHadditionaltime <br /> billexpended <br /> by signaturethe <br /> andhour <br /> dateminimum <br /> belo Installation <br /> payment. The party must <br /> Name <br /> j6Dffl" "411 b�SLroiJ G . <br /> Mailing Address �• ►� IMS. �'�' p�'A-WMA <br /> C1 v-1 tvs-1 <br /> Day Phone Number (o to / <br /> Date_—,e_72 <br /> Signature <br /> EH 23 008 ( 1 /13/95, T Reg's May 5, 1994) <br /> 4 <br />