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_ SAN4PAQUIN COUNTY PUBLIC HEALTH SE'JICES <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-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 PHS-EHD UPON RECEIPT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # Paul %rf- ,� (,I*)&31_ 771 <br /> F FACILITY NAME 50Ujh,W-A 7 efeven PHONE # <br /> A <br /> C ADDRESS 4'Cv27 l>a V1hG1 prW6 <br /> I <br /> L CROSS STREET March Lane <br /> I <br /> Y OWNER/OPERATOR The �'1t2T1d PHONE # ('110 <br /> &31 -7711 <br /> �,C'r;carahOr <br /> C CONTRACTOR NAME _ eff,, �I► Yat101'i PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS A 6 VO4 <br /> T 1101 E• Sprirt fir fi, 5 3(033 41% Cz1 4Z7 G5*7 <br /> R HAZARDOUS WASTE CERTIFIED YES_�K NO WORK.COMP.# w G$17�1d3fo <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # TY H Q 44- 002 Z51 <br /> R <br /> illltllll!!l11111li1lllllitlll <br /> STAN ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- DATE <br /> T 39- —10,000 djgKonu Zt- Lk1iz9zw ::�. ImEs <br /> A 39- 1 �O b1t Pr�rnwv►� Un1E�ds�} t'1�l� <br /> N 39- ' <br /> K 39- <br /> 39- <br /> 39- <br /> P I111111111111111!lilllttllilll 1 !1111 7APPROVED <br /> L APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME -f[ ZIADATE <br /> ff(1'1Tfl'tTfliTlTl 11111 <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 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> / <br /> APPLICANT'S SIGNATURE: SC//ua+ (of RML CO-9 r1 Ceas��,�ITLE for 5gu%1-2na DATE 1fo 9b <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation <br /> payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name PHL. 1>G!ign Group Inc. <br /> Mai ling Address �o H�t�P /2YlU� J # .�-1- ; '�?aC1ramcnto , GA <br /> Day Phone Number (11&) (o4& -400-±) <br /> Signatur �— �ic w Date <br /> EH 23 00 (R v f2/130T, UST Reg,s May 5, 1994) <br /> UST SYSTEM DRAWING INFORMATION <br /> 4 <br />