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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <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. A PERMIT <br />MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY DAYS PRIOR TO THE END OF THE <br />CALENDAR YEAR. A ONE TIME, ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS LETTER. <br />DO NOT WRITE IN ANY SHADED AREAS. <br />PROJECT CONTACT: ; CONTACT PHONE # Zl _ Z(5: _`, <br />FACILITY NAME: lel FACILITY PHONE# _ / �3 S� <br />FACILITY ADDRESS: CROSS STREET: I V <br />f L' < LnaA <br />OWNER/OPERATOR - (� 1 PHONE: \ <br />CONTRACTOR NAME: ` - ` PHONE: q 26- - 27 -qW to <br />CONTRACTOR ADDRESS:Del CA LICENSE # CLASS: <br />"KIK `y TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br />APPROVED`APPROVED WITH COI <br />(see ae a�PitT�i� <br />PLAN REVIEWER'S NAME— �tJ� <br />DISAPPROVED <br />DATE k"a141L ------ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRAC OR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH T PERMIT ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WQRKER'S COMP o N LAWS OFyf <br />CALIFORNIA." <br />APPLICANT'S SIGNATURE:G,,� ' - -- TITLE DATEz-G�l Z_ <br />Indicate the responsible party to be billed f additions HD staff time expended beyond the 8 hour minimum installation payment. <br />The party must acknowle a this respon ibility for the additional billing by signature and date below. <br />Name z b i�1= �� /� <br />Mailing Address_ o �� L -D -Az;bl �0W <br />Day Phone Number- ' L4 to ( <br />Signatur C Date,,G <br />EH 23 008 (Rev 3/15/02) <br />4 <br />