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SAN JO,, ,UIN COUNTY PUBLIC HEALTH S.' VICES <br /> ` <br /> AVIRONMEN"IAL HEALTH DIVISION- <br /> APPLICATION <br /> IVISION / M� �0py <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSU I <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT E41 P.2)gton CTOSLe) PHONE# 9110- 774 -Z410 <br /> FACILITYNAME (p F jjj{ IF 440'1 PHONE# <br /> ADDRESS 150z N. E1 176ra6o St. 1ro61Lton <br /> CROSS STREET hard in 11J2 <br /> OWNER OPERATOR Glrcla k 5t Inc• PHONE#925-277-2319 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME John's �%G2J' PHONE# (7D7) 578- 1184 <br /> CONTRACTOR ADDRESS 1128 Hal �— rivG ante Rosa CA LIC# 3GIS2$ CLASS A Ham <br /> INSURER -5t2114Camp, Ir,&- Fund WORKER COMP# ItIZIlb <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME nota An21 ,'cal Labs. COUNTY Gontr26Y+-z 1 PHONE# q?. `188 ^IT( Oa <br /> SAMPLING FIRM P cff;c T&uq I PHONE # q16 - $58 -Z35o <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED <br /> 39- ,.O / 11, 6515 ul7r LJnle26ed 198 <br /> 39- b-Z _ Oz 11, Ss�S FrBm:om Unleaded I `1153 <br /> 39-16k Z-03 II $515 12;e l 1993 <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' .1 <br /> APPLICANTS SIGNATURE .tdw�^' of RHL TITLE F{a�_ Marr,{. dllT0OATE IZISO/9g <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> i <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPL ATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> rn <br /> c <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />