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SAN JOAQUIN COUNTY <br /> �,.,dVIRONMENTAL HEALTH DEPAF,,,AENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> WREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION. <br /> EPASITE# PROJECT CONTACT f7A ALU'i S PHONE ' 1001,1 <br /> FACILITY NAME ARC L- PHONE#- <br /> ADDRESS O 6M <br /> CROSSSTREET r-'4 T• <br /> OWNER OPERATOR nCtif4K �L-IL^ I PHONE# d 2 - - ' <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME I E-14CP / PHONE 400 4 - 2.d/ <br /> CONTRACTOR ADDRESS l bS9 LL{Ly- -����1W Z4 3 I CA LIC# ZOJ I CLASS /¢ <br /> INSURER I _ _ WORKER COMP# <br /> FIRE DISTRICT S Ocr./ rc AJL PERMIT# <br /> LABORATORY NAME C0UNTY10S &4(e PHONE 2 - Z72—Z O <br /> SAMPLING FIRM NI. ft AC-A(, I PHONE # 2ciTqL 7-LOO <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- IST ! ►l der.� U L6-wA/ f'oD J <br /> 39- <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 AGENTS SIGNATURE_CERTIFIES THE <br /> FOLLOWING: M 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 COMPENSATION LAWS <br /> .�OF-,C,AnLIIFFOORNIA,' <br /> APPLICANTS SIGNATURE (�Cf✓,IXC TITLE &I JAhf�/� <br /> DATE-Y,& 7s <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 3/15/02) Page 3 <br />