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zO� <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 REOUESTING 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 /> EPA SITE # PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME PHONE # <br /> A to Z <br /> C ADDRESS � <br /> �� � k 'mac iZ� <br /> L CROSS STREET <br /> v ,� l <br /> I r }y'". <br /> T COWNER OPERATOR PHONE # <br /> C CONTRACTOR NAMEr� -ss S �IL PHONE # <br /> 0 c3 <br /> N CONTRACTOR ADDRESS CA LIC # tij3d� �3 CLASS <br /> T <br /> R HAZARDOUS WASTE CERTIFIED YES k NO WORK.COMP.# `'- 17-' G 2 �- <br /> A yy L, 8 1'-I O Le <br /> C FIRE DISTRICT ' i� ©+ -j� PERMIT # <br /> T <br /> 0 BOARD OF EOUALIZATION # <br /> R <br /> 11111111111111 t 1111111 l i l t 1111 <br /> TANK 10 # TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALLATION <br /> 39- f 1C>no:-) I q IDATE <br /> T 39- 1 p o e) (73 n-.-,-1 ► I I -�-i"t <br /> A 39- ► 5 o c�c� rrb l t�� �G h� �•,� i t I I el-t <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39- <br /> P <br /> L PROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / ` `(SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ! DATE <br /> t111IlI1111111111111 1 1 it Ill 11 1 1 1 l II (11111 I I I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 70 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." L <br /> APPLICANT'S SIGNATURE: TITLE ��= 1( t�l DATE <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 responsibi,tity for the additional billing by signature and date below. <br /> Name '-1 L 1� 5 j -� . . �_ o-z��� Y�L �l+t r < 1—�cam) �m <br /> Mailing Address G' ��C', )-� �v� /�.v' �a1�, t��— e,O l-� <br /> Day Phone Number i Le 1—t <br /> Signature Date <br /> EH 23 008 (Rev 12/13/95, US Reg's May 5, 1994) <br /> 4 <br />