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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PUCE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # %S(02 PROJECT CONTACT 8 TELEPHONE # p9�2E Mc &lz&'IAVA„ 269-Sz•I-{ <br /> F FACILITY NAME PHONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET Mata SSA <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y <br /> CO CONTRACTOR NAME D L>eoT t cj S4 <br /> 6rk- PHONED ' RLn <br /> -7 -7 <br /> N CONTRACTOR ADDRESSQ',J` CSS <br /> T "A "R INSURER SGOf1YjaW� WORK.COMP-# N <br /> A n <br /> C FIRE DISTRICT GJ4.H So vN e.o UVt-.aV O r7i �(tJwt' 1.) A, PERMIT # <br /> T <br /> 0 LABORATORY NAME R,u�O� Mope,f Co, PHONE # <br /> R FSAMPLING FIRM -Pit ���-C-I/l (,..��fwE' Srfi PHONE 0 - YY -� <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY REVIO) DATE LIST INSTALLED <br /> 39- <br /> 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> j 39- J <br /> 39- <br /> P 111111 1 i 11 11(fiTl�lllllllllll <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SE ATTACHMENT WITH CDNDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 1111111111111 111111111 IffullIIIIIII <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANT PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> f"oa4e- �s(sfaMANot2 Qui <br /> 0 �- <br /> EH 23 046 (Revised 4/26/94) Pepe 3 <br />