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E-NVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK INSTALLATION PERMIT <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS 19 ONLY VALID FOR THE CALENDAR YEATHISR IN WHICH IT HA9 BEEN <br /> PRIOR TO THE NID OF THE CCALENDAR YEAR AONE TIME,ONEYEAR EXTENSION MAY E GRANTED BV EHO UPON RECEIPTF THIS LETTER,DAYS <br /> PROJECT CONTACT: CONTACT PHONE# <br /> L ANc� 8c/h�csyr/aA qts 697- a78S <br /> FACILITY NAME: FACILITY PHONE# <br /> -� ga5- -6 23S <br /> /cs CAC'(�Sp" � G v5-0 CROSS STREET: <br /> FACILITY ADDRESS: <br /> /3 c/7s- 49 N 8e/ Z Oc%Er-o2p,ca 93' 37 <br /> OWNER/OPERATOR: PHONE: <br /> T&so/zo /•/�-�,7—coAsr Cc c . qzs- X87 - a7B3 <br /> CONTRACTOR NAME: PHONE: <br /> /,6.,8 L45, -7o-7 <br /> CONTRACTOR ADDRESS: CA LICENSE# <br /> 3-day pjlontaL SArJrF (ZosQ, cP us{o� 3128y�1 _ <br /> HAZARDOUS WASTE CERTIFICATE: WORKERS COMP# <br /> ✓YES NO WPLs0o0 (o0303 <br /> FIRE DISTRICT: PERMIT# <br /> BOARD OF EQUALIZATION# <br /> TANK ID# TANK SIZE CHEMICAL STORED PROPOSED INSTALL DATE <br /> PSOL. �. 3(2G !'2 <br /> 3 B. ss6t 3 76 !Z <br /> O APPROVED (��//�lf;�y� PPROVED WITH CONDITIONS DISAPPROVED <br /> i�`l"�' se attachments) �,� �-12— <br /> APPLICANT <br /> ^ <br /> PLAN REVIEWER'S NAME DATE L <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, <br /> RULES AND SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S <br /> SIGNATURE CERTIFIES THE FOLLOWING"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br /> PERMIT IS ISSUED., I SHALL NOT EMP ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LA CALI RN " CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br /> CERTIFIES THE FOLLOW! TIFY T T E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS <br /> ISSUED,I SHALL EMPLO a " NS CT ORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> ---*Applicant's Signature ! 2-01Z-� <br /> .--.*Title -Z9 NGCrCon7sTkUo7/aa t fsl Cry.. Date <br /> Indicate the responsible party to be billed for additional EHD staff time pen ed 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 L AAIC5 2(We-Allvl Date .('160/Zp(Z- <br /> __ <br /> Mailing Address q/00ie X004( 7''ei/ ^,j A'A((�AI(a' T 78ZSk �� <br /> —4 Signature Daytime Phone q25-4� $-7-2781 <br /> Revised 8/1/11 3 <br />