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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X_ NOWAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 5 <br />EPA SITE f C, p-(�(�() . U�(� �,6 <br />PROJECT CONTACT L TELEPHONE #&N �L7 �j.1�{.,(,L 4 tq <br />F <br />FACILITY NAME <br />PHONE f <br />C <br />ADDRESS �. srv� Aj� S �ToO 95Zs��- <br />I <br />1 <br />L <br />CROSS STREET �� (,� h�,� o <br />1 <br />TLUHER/OPERATOR <br />A (In n ^ ' { <br />PHONE ! (40� 2� <br />, '�� 'y I A� <br />C <br />CONTRACTOR MAKE <br />T-Yf'L�L-G <br />PHONE IT <br />0 <br />N <br />CONTRACTOR ADDRESS o STDL�CiO1J gC�Li3 <br />G LIC f 3�5Z3 <br />CLASS <br />T <br />R <br />INSURER N <br />WORK.COMP.! n 7 <br />�-% <br />C <br />FIRE DISTRICT ITY OF TOCKTON <br />PERMIT IF <br />T <br />0 <br />LABORATORY MAZE <br />PHONE f <br />R <br />SAMPLING FIRM PHONE IF <br />TANK ID f TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- -? —c,� <br />T <br />39- <br />A <br />11- <br />w <br />39- <br />K <br />39- <br />39 - <br />{iii nm{ r <br />P <br />L APPROVED APPROVED WITH CONDITION(t) _ DISAPPROVED <br />AS E ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME ����� �r-r DATE <br />{1{{{i{{{{{{{{{{{{{{ mMM=irrrnmr1111 { <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AMD REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 01 CERTIFY THAT IN <br />THE PERFORMANCE OF THE (ARK FOR WHICH THIS PERMIT IS ISSUED, I SHALL HOT 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 PERFOR•VNCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFCOOIA !, <br />APPLICANT'S SIGNATURE: TITLE ^�-I/ `-•N/'. , DATE <br />EH 23 046 (Revised 7/10/92) Page 5 <br />