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o . <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK INSTALLATION PERMIT <br /> APPLICATION FOR INSTALLATION OF UNDERGROUND TANKS ARE ONLY VALID FOR toe 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-END 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-END UPON RECEIPT OF THIS LETTER. <br /> bO NOT WRITE IN ANY SHADED AREAS. <br /> EPA SITE N -7S f PROJECT CONTACT A TELEPHONE N 'n l 016) <br /> F FACILITY NAME C��G / Q'� PRONE * <br /> A <br /> C ADDRESS �J�,� G) JQA6I L L i >LL <br /> t <br /> L CROSS STREET <br /> t OWNER/OPERAT P ONE A <br /> ► SID V7 r - lc <br /> C CONTRACTOR NAME wd9T PHONE N(/'/®J t/q7- L's� <br /> N coNtRACTOO ADDRESS _<r,7 �"'v CA LIC 0 el Z(® CLAss ,Q— <br /> t Go 9y� v <br /> R HAZARDOUS WASTE CERTIFIED YES NO WORK.COMP.S <br /> A PERMIT <br /> C FIRE DISTRICT u` <br /> t _ <br /> d HOARD of EQUALIZATIoN 0 <br /> R <br /> J <br /> TAN <br /> II�Ilifril �l 1i111�l1�1f <br /> TAN tD ' TANK SIZE s CHE1ilCALS TO E STORE O PROPOSED INSTALLATION <br /> f �` <br /> i DATE ' <br /> fjl <br /> t 39- SCL" <br /> A 39- _ <br /> N 39- <br /> K 39- <br /> 39- <br /> 1111 <br /> P APPROVED APPROVED WITH CONDIttON(S) DISAPPROVED <br /> SSE tACHMENt WITH CONDITIONS) DATE <br /> g. <br /> N PLAN REVIEWERS NAME <br /> 11111111111111111 11 (11111111111tllll <br /> APPLICANT MUST PERFORM ALL WORK 14 ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. WHEN OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING., "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH 1010 PERMIT 19 ISSUED, 1 SHALL Not EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT t0 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING., <br /> "I CERTIFY THAT 10 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> •fit con f� a c�� <br /> APPLICANT'S SIGNATURES TITLE DATE <br /> Indicate the responsible party to be billed for additional PHS-END staff time expended beyond the 8 hour minium installation payment. <br /> the party must acknowledge this responsibility for the additional billing by signature and date below. <br /> N� S <br /> Nailing Address t <br /> Day Phone Number 6 �2 <br /> Signature L Date <br /> to 23 008 (Rev 1/?/92) WP <br /> . 3 <br />