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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <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 /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PI.ACE <br /> FACILITY INFORMATION <br /> EPA SITE# - Z- PROJECT CONTACT G°c�+ J % PHONE# �'f, —` •y 7�7 <br /> FACILITY NAME �- ✓41 "� / PHONE# <br /> ADDRESS ?<,SP Ji,l!' T U - G6% ,dGE e T z 8 <br /> CROSS STREET /7,5,K/ r <br /> OWNER OPERATOR - GcUeu D7117J2ZI-OR4PHON <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME �f/. G%A^r'• lAAl HONE# /E � <br /> CONTRACT OR ADDRESS u dve, -K i- f ShG/6,Ce CALK .3��� CLASS ,U-G-U Nq2 <br /> INSURER c e •wL �1� G` WORKER COMP# 77- 2- <br /> FIREDISTRICT iS%N/C% 2.y 'ITT•J �• �' PERMIT# a 6 S <br /> LABORATORY NAME COUNTY 4 IPHONE# <br /> SAMPLING FIRM n PHONE# B <br /> TANK INFORMATIQfl <br /> TANK ID# TANK SIZE TANK CONTENTS PR ENT AND PAS DATE INSTALLED <br /> 39- 7" %7` T <br /> 39- <br /> 39- <br /> 139- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9-39- <br /> 39- <br /> 39- <br /> 39-APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WIT AN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND S` I„ <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTA HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE `W <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF T 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 MPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENS ION LAWS OF CALIFORNIA." ( // <br /> APPLICANT'S SIGNATURE TITLE /Yr'/n QI: Po.��l✓/ SD'ATE 7�'/'-� <br /> ❑ APPROVED APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM IS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 10/30/12) 3 <br />