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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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 /> RREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> j " FACILITY INFORMATION' <br /> EPA SITE# D/#D(&SyU PROJECT CONTACT lrY'J c� . �� /7Iii7tZ 1 PRONE# LS-744 <br /> FACILITYNAME reit' J L�.�7[yJGT` PHONE# 70 7 <br /> ADDRESS �%/5 LC• //"TU.Sr' w C <br /> CROSSSTREET 461- St': <br /> OWNER OPERATOR L i c5 7)- -Cr PHONE# <br /> IKCONTRACTOR INFO ' s <br /> CONTRACTORNAME � e'° I f; I LPrI F : tD Sj' b'ice,p PRONE <br /> CONTRACTOR ADDRESS i/ . 6 t'x ) I-, !a + L�%C -.I/{,/�.yl r4 CA LICA#rye 3G-7'�j[5"71 CLASS 4-__ <br /> FIRE DISTRICT ej 7`L 07L Tl'/jCx PERMIT# /Q/� r�.Z <br /> LAB ORATORYNAME ' I l"1L COUNTY PHONE#S3 <br /> SAMPLING FIRM e-17(J; ,rA )cele- PHONE "7 <br /> TANK INFORMATION ;. <br /> TANK IDM TANK SIZE `ANK CON-FITS PRESENT& PAST) DATE INSTALLED <br /> 39' 000 �l 0!� /et <br /> Uu/?�i2+��✓J <br /> 39_ <br /> �9- <br /> M9._ <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: '1 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 <br /> EMPLOY PERSONS SUBJECT TO WORKER'S[COMPENSATION LAAWQ��'OF CALIFORNIA.° Sy/7,,y'/�- <br /> APPLICANTS SIGNATURElTITLE 1071/4 DATE I <br /> "❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> 1 ,f r('SEE CONDITIONS SELCW AND/OR.ON ATTACHMENT). <br /> PLAN-REVIEWER'S NAME 9)ATE 'I6`0 <br /> ANY DEVIATIONS'FROM THIS:AP-PLICATION'-MUST BE"3 UBM 117EDTO+EHD FOR-APPROVAL.PRIOR TO,COMMENCING)WORK. <br /> . <br /> GONDIT104s, <br /> GFE ig'i'SW�Gt'1�f� <br /> EH 23 046 (Revised 11/21/06) Z <br />