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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDCUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> )�,- REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # Ab9s'lL PROJECT CONTACT & TELEPHONE # '�cTr?CtLiL ,0 7i4 kzlo_o�.5z.. <br /> F FACILITY NAME I PHONE *;L Oct 3101,19 <br /> A `, <br /> C ADDRESS &- Ono.YID aJ" <br /> I <br /> L CROSS STREET N <br /> T OWNER/OPERATOR PHONE - <br /> Y v-�a�\ ATYURt� a1 �; Wuz 44 - g55 <br /> C CONTRACTOR NAME 0 0' ri'L Y PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS I CA LIC # 3 00 34 5 CLASS <br /> vt. <br /> T <br /> R INSURER � � WORK.CCMP.# 2�4 pOzgZo <br /> A <br /> C FIRE DISTRICT I PERMIT # <br /> T <br /> 0 LABORATORY NAME \ ` COUNTY b PHONE 0S1S $E') -SSfjp <br /> R <br /> SAMPLING FIRM Blgu � rn{-�` I PHONE #(607.) yq3^3SSS <br /> TANK [D TANK SIZE CHEMICALS STORE? CURRENTLY/PREV[WSLY DATE UST INSTALLED <br /> 39- r - / X;" G h\ i <br /> T 39- - S- _,_'ar leo\\�•- S.aW _ D� . \ — yo ILj9Awy <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L _ APPROVED x APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N ��4�t <br /> PLAN REVIEWER'S HANEy,P.rG TjEi�It�VDATE <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: "I 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 BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I 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 SIGNATURE: TITLE VI La. {'#i(IOA DATE I2J2I'1b <br /> cormlTloNcs>: ytr) 0ooyE SEE y46E 8 / LA6w,4rbv—clr fl�At Y5 5 2CQ�rBE.�6„1 . <br /> Post-it'Fax Note 7671 Dace 9 r»D-1 <br /> To From <br /> Co./Dept r Co. <br /> Phone# Phone# - <br /> EN 23 0,�6 (Revised 7/i0/96) Fe"# 333—68 Z Fax# 6 -a C3 <br />