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V� FEE-02.04 17:28 FROM-KLEEMAN ROESSELEN 916-939-1169 T-746 P.07/17 F-539 <br /> .. ` w <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT Fop PERMANENT'EMPORARY CLOSURE OR AMANOONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUSSTANC&S <br /> STORAGE TANKCSI EXPIRES 90 DAYS FROM THE APPROVAL DATE- DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> Q REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE F PR IECTCONTACT PHONES 479-4 <br /> FACILITY NAME PHO N <br /> ADORES$ '6 QMSz/1— <br /> CROS55TReET — 0#c;5` DIY 11y� <br /> p%NNER OPERATOR -S'8 C PHONE R <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHON67) I - IO <br /> CONT ACTORADDRE66 Z G CAL A O CLASS <br /> INSURER e ASS✓R, T'�L� N� D PW ®O ' <br /> FI RE P19TRICT PF 14Ri <br /> LASORATORYNAME G .AP'7 CO NTYP ONE* <br /> SAMPLING FIRM L PHONE v - <br /> TANK INFORMATION <br /> PNENTq p TANKSIZE TANK CONTENTS <br /> 39- U Z -04500 (S44 Dl&SEL FK64 fue Sr4A< .9y /98S <br /> 39_ �v1s�QeA.cY ®wee aroz <br /> I 39- <br /> 39 <br /> 39- <br /> 39- <br /> APP4ICANT MUST PERFORM AµWORN:IN ACCORDANCE WITH SAN J. OWN COUNTY ORDINANCES,STATE LAWS,FEDERAL STH AND RULES AND <br /> RECTiF nTM S IN SAN aOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR ISSUED. <br /> I SM AGENT'S SIGNATURE LOYANY GER ON I THE AMAN INC: S <br /> CERTIFY THAI IN TliC TO WO KER'S O PE WORK FOR WRICH TMS PERM'IS IS6DED,t SMALL I NOT EMPLOYANY PERSON BI SUCH AMANNER AS <br /> TO FDLi.D iNG -iSUBJECT TD WORKER'S COMPENSATION WWB OFI WORK NIA' OONTRACTOR'S HIRING OR D.ISHALL AGNNG PERSON S CERTIFIES <br /> TME FOLLOWING 'I CERTIFY THAT IN THE PERFORMN E CP TH9 WORK FOR WHICH THI6 PERMIT IS ISbuED.l SHALL EMPLOY PERSONS SUBJECT TO <br /> W ORKER'6 COMPENSATION L4w3 OF�ILIFORNIA <br /> APPLICAN-SSIGNATURIE TITLE �- fW�Gfj7���DA7P 7 -14 <br /> / 4 <br /> ElAPPROVED 12APPROVED WITH CONDITION(S) C ❑ DISAPPROVED <br /> ISEE CCWPRIONS BELOW ANDIOR ON ATTACHMENT) �'I <br /> PIAN REVIEWER'S NAME -'4511 L-- DATE 1_) V <br /> I ANY DEVIATIONS FROM THIS APPLICATION MUST BE OfAMITTED TO BHP FOR APPROVAL E8192—r9_1 WORK, <br /> CONDITIONS: <br /> I <br /> I <br /> EH 23 046(REVISED 06113/99) Pepe 9 <br /> I <br /> RECEIVED FEB-11-04 15:09 FROM-9168581011 TO-KLEEMAN ROEBBELEN PAGE 05 <br />