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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 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 />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 f? /� /`(� lZ Ut�O ! ��rr®�,�C .�/ (� 7"5%i G <br />Mailing Address En t z2i o a 7 CG(. 9Y$^,3 77" <br />Day Phone Number <br />Signatur <br />EH 23 00 <br />, UST Reg's May 5, 1994) <br />2 <br />Date to <br />EPA SITE # C194 000OZ3338PROJECT <br />CONTACT & TELEPHONE # / C �[. t U -? 3 <br />F <br />A <br />FACILITY NAME S <br />O # / <br />PHONE # a ® y/ -71Y,9 <br />f <br />I <br />I <br />ADDRESS 93 a <br />/ <br />O n C t® b <br />J <br />L <br />CROSS STREET <br />I <br />b <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />®- <br />® - :F- — S O O <br />C <br />CONTRACTOR NAME 7c"-% �c Pt <br />hi�ihr <br />PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS <br />CA LIC # <br />CLASS <br />T <br />R <br />HAZARDOUS WASTE CERTIFIED <br />YES NO WORK.COMP.# <br />A <br />C <br />FIRE DISTRICTC/ y <br />PERMIT # <br />T <br />b <br />C A <br />0r39 <br />EQUALIZATION # <br />R <br />TANK ID # <br />TANK SIZE CHEMICALS TO BE STORES PROPOSED INSTALLATION <br />- <br />C t dDATE <br />T <br />ed I JLCL/5�irs <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L _ <br />APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME <br />1l11l11!lililillill!! !i ill1111111l11lill! <br />DATE <br />I!l111ll1illl111 1!! ill111Ui1111l1i11!!l111111111l11lliill!!(illllillili! <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 PER RMA N <br />0 THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OLI 0 NIA. <br />LE: <br />APPLICANT'S SIGNATU <br />TITLE 0- - DATE A -UA tf <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 f? /� /`(� lZ Ut�O ! ��rr®�,�C .�/ (� 7"5%i G <br />Mailing Address En t z2i o a 7 CG(. 9Y$^,3 77" <br />Day Phone Number <br />Signatur <br />EH 23 00 <br />, UST Reg's May 5, 1994) <br />2 <br />Date to <br />