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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 />DO NOT WRITE IN ANY SHADED AREAS. <br />EPA SITE # GAri ' (OUL <br />F FACILITY NAME �Y `G e y <br />A <br />C ADDRESS r <br />I <br />L CROSS STREET NEAL Q <br />I <br />T OWNER/OPERAT <br />Y J <br />C CONTRACTOR NAME C' ? ' j({ <br />0 __ssccss <br />N CONTRACTOR ADDRESS <br />T 7 (,—ClIANC <br />R HAZARDOUS WASTE CERTIFIED YE <br />A <br />C FIRE DISTRICT I/ <br />T ! Y <br />0 BOARD OF EQUALIZATION # ' <br />R <br />PROJECT CONTACT & TELEPHONE # y n <br />NO <br />lJ <br />Chi CA LIC # <br />'PAAM Oi6) 1T*?21??.. <br />PHONE <br />lf)A6 uln "o tkl� <br />P��1 6-te(4 <br />PHONE # c�I C� <br />1 CLASS <br />WORK.COMP-# 571 I� 8 <br />PERMIT # <br />1111111111 <br />TANK 11111111111111 <br />TANK ID # TANK SIZE CHEMICALS TO 8E STORED PROPOSED INSTALLATION <br />39- 1 I o0 L1_VI1� e- SU DATE <br />T 39- ' L/1 I I i2n S <br />A 39- <br />N 39- <br />K 39- <br />39- <br />IIII <br />P <br />L _ APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />illllllllllllllllill 111111 1 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 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 />�lj Cc fl -a Gf Old <br />I %/lD e ATE <br />LICANT'S SIGNATURE: 1 �( P�th.�� TITLE / <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 ackno <br />wledge this responsibility for the additional billing by signature and date below. <br />Name j <br />Mailing Address 1 1 Yi�Q ��C�T �Vt��TC "/ X I) but <br />f [�^ i� /� 6k "{ ��"1L <br />Day Phone Number 6 j <br />Signature <br />r 'L t Q. Date <br />EH 23 008 (Rev 1/7/92) <br />3 <br />