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C7 <br />v <br />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 />EPESITE # PROJECTCONTACT & TELEPHONE # X ICt4vnt- WAuT-04 qyF FANAME ® F{ d? PHONE # Z p cd 3 ` Cl (j y <br />A � / <br />C ADDRESS �8- O V i C-t—O✓t. �L� <br />i <br />L CROSS STREET W Ct C1 <br />I PHONE # <br />T OWNER/OPERATOR 2- Q Cf — 3 C `l (Oct <br />Y So X- Si .( C✓t� <br />C CONTRACTOR NAME I I,( I ►j-( 1 -Kc L PHONE # cl(6 _ 3 <br />id1- SALt'vCA CA LIC # fal i CLASS A t�A� <br />N CONTRACTOR ADDRESS P• C)^ 6 o )C 10 Z T' T b n <br />T WORK. COMP. # '� 1� _ c/ Cj Z ^O U <br />R HAZARDOUS WASTE•CERTIFIED YES NO <br />A PERMIT # <br />C FIRE DISTRICT <br />T <br />0 BOARD OF EQUALIZATION # <br />R <br />IIIIItllllANK I11111t11111t11 ID # TANK SIZE CHEMICALS TO BE STORED �� �� PROPzosEDDATETALOLAitON <br />TANK <br />39- 03, l Z � 000 •D ( E-5 tf� <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- Tff(111Tf11T{1T <br />11t1 <br />P <br />_ AP VED APPROVED EE ATTACH MENTITH CONDITION(S) WITH CONDITIONS) — DISAPPROVED <br />L <br />ADATE 312 OZ <br />N PLAN REVIEWERS NAME <br />1111111111111111111111Itllllllllltllllll111111111111111111111 111111111111111{1111111111111II111111IIII1111111111111111111111 <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: 111 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 />"1 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 />APPLICANT'S SIGNATURE: TITLE �n DATE <br />iM l C fA A- - WA (--F <br />-END staff time expended beyond the 8 hour minimum installation <br />Indicate the responsible party to be billed for additional PHS <br />payment. The party must acknowledge this responsibility for the additional billing by signature and date below. <br />Name Z 011- ik – ' Iii <br />Mailing Address ? �S O <br />Day Phone Number <br />Signa <br />EH 23 <br />W <br />(Rev 12/13/95, USY Reg's May 5, 1994) <br />.© <br />Date <br />