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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERINUT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL ;k,,/TEMPORARY CLOSURE azjr CLOSURE IN PLACE <br /> fE SITE Y ,�C�O PROJECT CONTACT b TELEPHONE ! <br /> ILITY NAME N- yLt013PHONERESSSS STREET CLPHONEER OPERATO 'JQq N1os'-T Mvrddx1< <br /> C CONTRACTOR NAME ��i I e, L Y11 fGC}'Jf I PHONE X 3.�o9) bl- 10 33-! <br /> N CONTRACTOR ADDRESS `�� CJ `vj LV Lim f . G LIC B L1 ;J 7� (� I CLASS F'1 <br /> T <br /> R INSURER F0.}C FUn� I WOI(X•COMP.: _2,9- O 09 341 - 9 <br /> C FIRE DISTRICT CET ,n s� �� ( PERMIT CIU 3 ` <br /> TPHONE <br /> 0 LABORATORY NAME I COUNTY <br /> R I PHONE N <br /> SAMPLING FIRM <br /> Ililiil11111111111111111111111 <br /> TANK SIZE CHEMICALS STORED CURRENTLY PRE'/IOUSLY DATE <br /> TANK IDX yST INSTALLS] <br /> 39- — 12 OCX� pct {-ec�ifcar tinlec.ded �As 13. 184 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P III( IilllllIII IIIIIIIIIII Ill I 1 I I 111111 111 II 111111111 11111111111111111111111111111 <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> " �I ��� - <br /> PLAN REVIEWER'S NAME GATE <br /> lllllllllllllilll11111111111111tII1111111111111111Illillllllllilllllliillllllllllllllllllllllllllllllillllllllllllllillililtl , <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 111 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 3ECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 1-1 CERTIFY THAT IN THE 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 <br /> ALIFORNIA-"APPLICANT'S SIGNATURE: TITLE DATES <br /> O� <br /> w,µ„ h� scr� V7- , <br /> .3 _ C' <br /> EH 23 046 (Revised 7/10/96) " R'L Page 3 <br />