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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE 1 Solt ✓•C <br />EN 23 046 (Rev 11/7/90) It Page 3 <br />EPA SITE # %% <br />PROJECT CONTACT & TELEPHONE# <br />/ �,, r7 <br />DD /� <br />F <br />FACILITY NAME ;,,) <br />PHONES # <br />_ 1• <br />f� <br />A <br />C <br />ADDRESS I <br />I <br />L <br />CROSS STREET <br />C L <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />76-7-36 9T <br />I <br />D, <br />C <br />{ <br />CONTRACTOR NAME Q/1 �,� EGY't�i <br />PHONE # !1 <br />►`v+J w'10 JC 1 v1 Cr .r 0 <br />D _ <br />ZrZ L/ <br />0 <br />N <br />CONTRACTOR ADDRESS SGS CA LIC # <br />Ll y q O-? ` <br />CLASS A - <br />T <br />R <br />INSURER1 <br />WORK.COMP.# �• <br />�., f. <br />A <br />C <br />FIRE DISTRICT N <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME /'I G <br />It <br />PHONE <br />L� / <br />R <br />I <br />PHONE #_ <br />SAMPLING FIRM' �, % S �n �I iC r' -C"TG, I 16 <br />IIIIIIIIIIIIIIIII1111111111111 � � � <br />TANK ID # FoeTMee TANK SIZE CHEMICALS STORED CURRENTLY/PRF,VIOUSLY DATE UST INSTALLED <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />IIII11111111111111111111111111 IIIIII11111111111111111111111111 IIII11111111111111111111111111111111111 <br />IIIIII111111111111111 <br />P <br />L <br />_ APP OVED APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />(SEE ATJfMENT CONDITIONS) <br />N <br />PLAN REVIEWERS NAME 111A A <br />DATE <br />IIIIIIIIII11111111111111111111111111101111111111 ll11111111111111111111111III111111111111111111 II 11111IIIIIIIII11111111 <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />ANY PERSON IN SUCH MANNER AS TO BECOME SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." a <br />APPLICANT'S SIGNATURE: - TITLE <br />.41 <br />DATES <br />EN 23 046 (Rev 11/7/90) It Page 3 <br />