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SAN JOAQUIN COUNTY PUBLIC HEALTH / <br /> ENVIRONMENTAL HEALTH DIVIS. �s� z, Q d 7 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK I ` 0 <br /> THE APPLICATION FOR INSTALLATION OF UNDERGROUND STORAGE TANKS IS ONLY VALID FOP <br /> PRIORMTO ITHE ENDEOFETDHEDCALENDARTHE <br /> YEAR. CALENDAR <br /> TIME, ONE YEARTEXTENSIONSENT <br /> MAYOH <br /> BEC <br /> DO NOT WRITE IN ANY SHADED AREAS. <br /> PROJECT CONTACT 8 TELEPHONE # <br /> EPA SITE # <br /> PHONE # <br /> t <br /> F FACILITY NAME LOV1t.S 0�.�.�� <br /> A <br /> C ADDRESS £ n�s n /, <br /> I S�wil,Q.,.rt ��.�I� To�e fid. J r(Gl <br /> L CROSS STREET COv4w O P ONE # <br /> Ion) <br /> T OWNER/OPERATOR <br /> Y L uv jS <br /> 1 PHONE # <br /> C CONTRACTOR NAME W:1� � j JL W�QM �Ok�CracE �K O�vardII� CLASS <br /> 0 CA LIC # <br /> N CONTRACTOR ADDRESS WORK.COMP.# <br /> T YES NO <br /> R HAZARDOUS WASTE CERTIFIED PERMIT # <br /> A <br /> C FIRE DISTRICT <br /> T <br /> 0 BOARD OF EQUALIZATION # <br /> R <br /> llllll"llliiiililillliiiillilEMIT LS 0 c STOR Dr PRppPpOSED iNSTALLATI N <br /> TANK SIZE '�pCAs�i��t No% DATE �00 <br /> TANK ID # a Q 00 O <br /> 39- L tAr Oto ;."I <br /> T 39- �-L�poo - 11 <br /> A 39- o 0 <br /> N 39- o poo <br /> K 39- <br /> 39- <br /> 39 <br /> I'llAPPROVED WITH CONDITIONS) DISAPPROVED <br /> P APPROVED <br /> L (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> A <br /> N PLAN REVIEWERS NAME <br /> lillllllillllllllllllllllllilllllllilllilllilillllJOAQUIllllllillllillllilll ANO RULES IAND IREGULATIONS lo!i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN ER OCENSDN COUNTY ORDINANCES,CERTIFIES THE FOLLOWING: 111 CERTIFY THAT IN <br /> STATE LAWS, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> PERMIT IS ISSUEDEIASMALL SNOT GEMPL NATURE Y ANYPERSOIN <br /> NSI SUCH <br /> A MANNER A TO THE <br /> THE PERFORMANCE OF THE WORK FOR WHICH <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT �SeI C`U_E�D,rIrsMA 'EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." r0Y ( QV R 1 o �7 S QQ �� <br /> �.7 TITLE Oar e �OF E.V. I DATES <br /> APPLICANT'S SIGNATURE: <br /> Indicate the responsible party to be billed for additionafoHtheHadditionaltime <br /> billingdby signaturethe <br /> andhour <br /> datembeloww. installation <br /> payment. The party must acknowledge this responstbiltCtY <br /> Name LSV <br /> Mailing Address <br /> iZ6 <br /> Day Phone Number C 4 �` "� '4' <br /> 7 - <br /> y — l.�l-oo <br /> V' Date <br /> Signature1994) <br /> EH 23 008 (Rev 12/13/95, UST Reg s May 5, <br /> 4 <br />