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ENVIRONMENTAL HEALTH DEPARTM91ICEIVEL <br /> SAN JOAQUIN COUNTY MAR 10 2016 <br /> APPLICATION FOR UNDERGROUND STORAGE TAN AVIRONMENTAL <br /> CLOSURE PERMIT H!FA'Tu n=0i0TAACh,-r <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE PROJECT CONTACT 41-Fle4EP PHONE#Z C/,2 <br /> FACILITY NAME CSL/ r i2/17 1-1'20 -47;;- PHONE# <br /> ADDRESS ,3 C n1Ac-- S 1110le <br /> CROSS STREET <br /> OWNER OPERATOR /Z Q PHONE#2-6193,.1, 91 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME �/��/ 1 Q/Z/�,� 0i/- /lI " PHONE# ZB 36SG� <br /> CONTRACTOR ADDRESS 60 �J/ L CA LIC# 6 CLASS / 9Z <br /> INSURER ,,/ ff�- WORKER COMP# y /`z/r✓/ �/ - Ej <br /> FIRE DISTRICT - / PERMIT# <br /> LABORATORY NAME SSD 9 %C4 COUNTY5 / S1 PHONE# ZO 966 P�/OO <br /> SAMPLING FIRM C2 PHONE# Zo O <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- ® 2C 57401 S DLI- * �1k- <br /> 39- /P/2D/7c/G r ✓ lzakv,�� <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I C TIFY T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO W O LAWS OF CALIFORNIA" /� <br /> APPLICANT'S SIGNATURE i - L TITLE�4/C(,/6_ ` \ DATE <br /> APPROVED WAVPROVED WITH CONDITION(S) DISAPPROVED <br /> E COND I NS ELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> nTTn^ AAL /T),._.:.....1 7n/th/n 117 C\ 7 <br />