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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTIVrENT <br /> ON`FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> Vic.ENT/1'EMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> �yc890 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> •VAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> '/TCA OO ) /D PROJECT CONTACT ZA V S ° PHONE# <br /> E / �vo0(2AL PHONE# 9/6 <br /> 93 - pPZZ <br /> S :m.., RN o 7' eAJC@A3'0jC <br /> ACROSS STREET e OK <br /> OWNER OPERATOR /T ra e/c �o M PHONE# /G 7 <br /> ri. <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME G C'D FO N / /-/C PHONE# <br /> CONTRACTOR ADDRESS © I N T.9 c 1 . S U I T(F ID'i CA LIC#C 1.3 <br /> 7 CLASS A CS7 NA idAC <br /> INSURER n( o WORKER COMP# j o a- 6 7 Cess cr e l <br /> FIRE DISTRICT Cl7' Lf S/ O CK 7 U N PERMIT# <br /> LABORATORY NAME (rlfklCOX N/N /ACoadroA['/ CA'anrCW4 PHONE# /4) 638' '730 <br /> SAMPLING FIRM r,,-O�-oN a K N rf (� I PHONE # 19/, / -3 6 a <br /> TANK INFORMATION <br /> TANK ID# FT7ANKSIZE TANK CONTENTS PRESENT& PAST DATEINSTALLED <br /> 39- epT/1,/ a39- 7- <br /> 39- <br /> 39- <br /> 39- <br /> 1 <br /> n G o L <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE 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 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY <br /> PERSONS SUBJECT TO WORKER'S CO A NSATION OF CALIFORNIA.' ') TJ ,/ <br /> APPLICANTS SIGNATURE TITLE r%J6 U/f'dAONS //./N/c^f0ATE Q .20 03 <br /> ❑ APPROVED PPROVED WITH CONDITIONS) ❑ DISAPPROVED .: <br /> (S/EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME /lJ C.�C.j�I,ii "C' � DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. - <br /> CONDITIONS: <br /> EH23046(REVISEDIO/16/03) - Page <br />