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a 0 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br />APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE 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 YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PHS-EHD UPON RECEIPT OF THIS LETTER. <br />EPA SITE # <br />F FACILITY NAME <br />A <br />C ADDRESS E <br />I <br />L CROSS STREET <br />I <br />TOWNER/OPERATOR <br />Y <br />C CONTRACTOR NAME <br />0 <br />N CONTRACTOR ADDRESS Okz <br />T <br />R HAZARDOUS WASTE CERTIFIED <br />A <br />C FIRE DISTRICT <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />TANK ID # <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />DO NOT WRITE IN ANY SHADED AREAS. <br />PROJECT CONTACT & TELEPHONE # <br />CA LIC # <br />YES NO <br />PHME # <br />PHONE # n <br />PHONE # <br />/ --? I CLASS �ks� <br />WORK.COMP.# <br />PERMIT # <br />TANK S I2,E CHEMICAt�,$ TO BE STORED PROPOSEDDINSTALLATION <br />f / <br />4 <br />P <br />L APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE _ <br />I l l l t l l l l l l l l l l l l l l l 1111111 III I I I "' 11 11 11 11 I """' <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 COMPETION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PE F N OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALI 0 I ' <br />APPLICANT'S SIGNATURE: TITL DATE <br />Indicate the responsible party to be bitted for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowleAge this responsibility for the additional bitting by signature and date below., , <br />Name <br />i��r�rcr�rr <br />Mailing Address <br />Day Phone Number <br />11�►� <br />11(�'M <br />EH 23 008 (Rev 1/7/92) WP <br />i <br />Date <br />