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Post-it@ Fax Note 7671 Date pagesI. <br /> To From <br /> Co./Dept. Co. <br /> Phone# /b - 0 Phone <br /> Fax Fax# <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDCUS SUBSTANCE STORAGE TANK <br /> - THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE- DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # CAC,OOI Oc54$08 PROJECT CONTACT 8 TELEPHONE # lA. u-fd Schr-ede! 911P $99 HU--I <br /> F FACILITY NAME e PHONE # <br /> rC ms - a 982. 4'-4I <br /> A <br /> C ADDRESS kp i-h R-tr 4 Loo , S+oc,ki-c>1 <br /> 1 <br /> L CROSS STREET +� <br /> I L- 1 y� I <br /> T OWNER/OPERATOR DStQ{� +I� •i�L ,Af-Cn14-er--+. PHONE # Q '/_ -1'1� Cep-1� <br /> Y r1G 1 �V Jul —10 I <br /> C CONTRACTOR NAME SAKI U L.Sch+edei' Q"-C,4� C-k� PHONE # CTO 2C)9 I I Q <br /> 0 O 1 <br /> N CONTRACTOR ADDRESSa�,8ox„gs � a--'� CA LIC #(ny�5q CLASSA H <br /> R INSURER � � WORK-COMP.#a'--I2-UN' 33(o- <br /> A <br /> C FIRE DISTRICT _ , PERMIT # <br /> T <br /> 0 LABORATORY NAME . PRONE # <br /> R SAMPLING FIRM CAetl LC=ch CdCr 0-Cn& CCC1.ial PHONE # qI(p 9q9 IIOy <br /> S <br /> TANKID II IIIIIIIII <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 11 111111 IIII 111111 11111111 II II I IIIII IIII <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( i AHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 'III'DATE Z <br /> IIIIIIIIIIIIIIIIIIII <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 p�.)nIF'/Z, DATE �i-S-9(o <br /> C°F�d)-I,eNb <br /> 1� TaNk- Mus-I- ba 30(65 Pe-e- 10009Otl. <br /> a) 0b-hq,„ Ftme weam; F -woe Rtrmn(ral 0V +arlr. <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />