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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION IT <br /> APLICATONAPPERMITIMAYFBE EXTENDEDT <br /> TINTO THEN <br /> NEXTRCALENDARKYEAROR INSTALLAION OF UDERGOND TANS AREI AONLY LETTER ISVALID FOR SENT OLPHSAEHDEREQUE TIENT <br /> NG TTHE CAENDR YAR IN WHMajgSH RTY DAYS <br /> PRIOR TO THE END OF THE CALENDAR YEAR. A ONE YEAR -- ONE TIME EXTENSION MAY BE GRANTED BY PIjfjff OPEN � PT OF THIS LETTER. <br /> DO NOT WRITE IN ANY SHADED AREAS. NS NCQAQI IN COUNTY <br /> HEALTH J <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # WA'T'ScI HMA BIW <br /> F FACILITY NAME MCC> (9tA M-- PHONE #e-2001) 9S-1 -2,gQ., <br /> A <br /> C ADDRESS -?O`c* oob of -z-lo <br /> I <br /> L CROSS STREET 4A r,l"SW_ J <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> C CONTRACTOR NAME -r%wa LNG. 6 �aAGib Lk PHONE #c1i� 4Z1 �qqp <br /> 0 <br /> N CONTRACTOR ADDRESS �► �.�X Z.W <br /> T D� CA TCA LIC # jt",a?j5 CLASSA,, RAS, JL <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.# ( We <br /> A <br /> C FIRE DISTRICT tPb 7N'`, ;=tow Pwr. PERMIT # <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> Illilllllliillllllllllllllllll <br /> TA ID # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- (,9 ,,HJT �d 0 00 C-r k.. 4q&61f 11jsr DATE Ot 0> <br /> T 39- 4W 44 t- co �. l.% c� 1 A <br /> A 39- _ � h 11 <br /> N 39- r D k u <br /> K <br /> ay- <br /> 39- <br /> 39- <br /> P Iliiffifffluflumm <br /> L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111111 II I 11111111111 ill II 11111111111 I III111111 <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 PERFORMA CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN ." <br /> r <br /> APPLICANT'S SIGNATURE: TITLE «'�`) L _ DATE Cp(2- a-2, <br /> Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name U�,t1cC�.. SIU WE.oe4r, no. <br /> Mailing Address Cf!"1 A gNr.> <br /> Day Phone Number <br /> Signature I/ 14ZI IW E. 1'11, SO.LJ Date 4;-WI-51 <br /> EH 23 008 (Rev 1/7/92) WP <br /> 3 <br />