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SA N JOAQUIN Environmental Health Department <br /> COUNTY <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 <br /> ISSUED. A PERMIT MAY BE EXTENDED INTO THE NEXT CALENDAR YEAR IF A LETTER IS SENT TO EHD REQUESTING THIS EXTENSION THIRTY <br /> DAYS PRIOR TO THE END OF THE CALENDAR YEAR. A ONE TIME,ONE YEAR EXTENSION MAY BE GRANTED BY EHD UPON RECEIPT OF THIS <br /> LETTER. <br /> PROJECT CONTACT: CONTACT PHONE# ,` Ic S-r <br /> FACILITY NAME: FACILITY PHONE# <br /> FACILITY ADDRESS: CISu CROSS STREET: <br /> D V,.-,C:, `D(-, Stec l Lj (1'l-U-L . L I <br /> OWNER/OPERATOR: PHONE: <br /> CONTRACTOR NAME: PHONE: <br /> L C. Sc-iZvT-c-�5 S r� Ll4 4 -1 3 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> YES NO (��a ��L <br /> FIRE DISTRICT: PERMIT# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> .vv f <br /> vL 2D I'd <br /> Lx� I L <br /> D APPROVED 0-APPROVED WITH CONDITIONS 0 DISAPPROVED <br /> (see attachments) <br /> PLAN REVIEWER'S NAME DATE I c <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,6TATE LAWS,RULES AND <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.,I SHALL NOT EMPLOY <br /> ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING "1 CERTIFY THAT IN THE <br /> 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 <br /> Title A-G&�q•ice -- Date <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond the 8-hour minimum installation <br /> payment.The party must acknowledge this responsibility for the additional billing by signature and date below. <br /> Name 7— Date I <br /> Mailing Address -Do t ,L'. 111 <br /> Signature --> Daytime Phone <br /> 3of8 <br />