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SAN JC UIN COUNTY PUBLIC HEALTH S /ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOS14RxE PERMIT <br /> THIS PERMIT FOR PERMANENTlTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> 2-REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> -- .-EPA_SITE# _Q O. �_ _ 1_PROJECT-CONTACT -I t7lZt.rt.l____jZ_L�-til _---P_HONE#- 3—(D <br /> FACILITY NAME L PHONE# 3 -3 4 t 6 <br /> ADDRESS , L' I Q Q <br /> CROSS STREET '"Q A C 16 <br /> OWNER OPERATOR T^j A PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME `J,= I PHONE* O -ML:,—1,5' <br /> CONTRACTOR ADDRESS p p` _ L3A,3 C` CAq CA LIC# 5 3 j I CLASS q <br /> INSURER WORKER COMP# Q <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME &Zo .-jA 47 Ak LA3 COUNTY 3j N S' PHONE;* 5'7 1—O 100 <br /> SAMPLING FIRM PHONE <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 190 \ i24 eU 2 7 u.jL ;\ 1):,0 <br /> 39- 1 C - C o ,gin. <br /> 39- 14 C occ Liz-,A o� <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWP OF CAUF0 NIA.' <br /> 1� � <br /> APPLICANTS SiGNATUR - � TITLE (-//��}b/"Aj ( DATE <br /> ❑ APPROVED EVAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> 1 \l! ✓ <br /> PLAN REVIEWER'S NAME DATE � <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> f CONDITIONS: <br /> J I ����r� 1 C� t 141 1"() <br /> Sl 6 ;/rl; <br /> ba 4 Ll r,9 -77-..� ci !,?r.- / X ru I jh Q/!n <br /> EH 23 046 (REVISED 10/19/98) Page 3 <br />