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-- -------------_�_� N/Js Jay <br /> ENVIRONMENTAL HEALTH DEPARIRm JIVE <br /> SAN JOAQUIN COUNTY , <br /> APPLICATION FOR UNDERGROUND STORAGE TANK JUN 1 12013 <br /> CLOSURE PERMITSANJOAQUI COUNW <br /> AL <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZADICA ENT <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICAT <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE INP E <br /> FACILITY INFORMATION <br /> EPA SITE# �� Z PROJECT CONTACT Lc."snPHON <br /> FACILITYNAME �- "]ADDRESS v c N/ Y ^ �•f Lb/ 'd N' cCROSSSTREET .GOWNEROPERATOR USN D I7 . <br /> CONTRACTOR INFORMATION <br /> r, <br /> CONTRACTOR NAME G'L/=+ a'1 c� c:Np ' ,-dart HONE# <br /> CONTRACTOR ADDRESS—30 mi/'AUG CALIC ,3a>73sus' CLASS u'-U Bu.. <br /> INSURER r ' L �H C WORKER COM <br /> C+ <br /> 72- ZL <br /> FIRE DISTRICT PERMIT# e) 8— G -3 L• Z <br /> LABORATORY NAME i •F T' c '-Inc. COUNTY c� HO E# Jo a.9 grOO <br /> SAMPLING FIRM /ter, PHONE# O <br /> ' r x; ". •h < �e1 TANKINFO RMATI <br /> TANK ID# TANK SIZE TANK CONTEN//TS PR ENT AND f'AS 7-17—DATEINSTALLED <br /> 9.au,� ;e"��.v ��' (M`i Ti <•S C,IrI X <br /> 7../7 -2 <br /> 39 �_ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LA AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL LTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> 'I CERTIFY THAT IN THE PERFORMANCE OF THE <br /> FOLLOWING: ORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S CO ENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY TH IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATI LAWS OF CALIFORNIA" ' -1 <br /> APPLICANT'S SIGNATURE TITLE �'Gr� /-✓~;�'�'''��l' ATE�l7`�- /" <br /> ❑:APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANC/OR ON ATIbACHMEN i) <br /> PAN REVIEWER'S NAME _— — — DAIE <br /> L <br /> ANY DEVIATIONS FROM THI APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 10/30/12) 3 <br />