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A^ so 40P <br /> 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 /> PROJECTCONTACT: P4: 1 CONTACT PHONE#SIZ .3t S- zszca <br /> FACILITY NAME: 7-E1 eue.,J $fie. 271,37 - 3z2.a:o2" FACILITY PHONE# 2Cxi_8s�p - �'jcc l7 <br /> FACILITY ADDRESS:2360 W. dtaAtV `Cie �� t CROSS STREET:TOe Rbam47o aKW�� <br /> OWNER/OPERATOR 7..C/tui vV XvVC. PHONE: 31 W3 <br /> CONTRACTOR NAME: PHONE: yZ j_ 2.487,t4 <br /> CONTRACTOR ADDRESS: LILI Ito OSSetl CA LICENSE# 7yq?38 CLASS: At <br /> uI<,I eD WA svzs- <br /> FIREDISTRICT, 0,1±!e 02 r <br /> TANK ID# TANK SIZE CHEMICALS TO BE STORED PROPOSED INSTALL DATE <br /> 10, oc3a t c <br /> APPROVED PPROVED WIT�CONDITIO14§--'Ni <br /> ISAPPROVED <br /> see attachmenonditions) <br /> PLAN REVIEWER'S NAME a, DATE f <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAbUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF <br /> CALIFORNIA." <br /> APPLICANTS SIGNATURE: � �� Z� or TITLEQkeo44t0N)6 /LJAAJAS[I�ATE 9-03 <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8 hour minimum installation payment. <br /> The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name C'h4CreJZC:�'tJU1t2Uril eYU��4l c'S /Ii2.t)�t^e5. Xye- , <br /> Mailing Address 4/q 16 RQ S5e l( 120 Mu kt (Tc® 04 ct 8 275 <br /> Day Phone Number <br /> Signature Date-. S-25 '03 <br /> EH 23 008 (Rev 3/15/02) <br /> 4 <br />