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F� <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION COR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />%. REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />CONDITION(S): �-, /O G1/Yl /YJ tf011,Lfi1'J <br />EH 23 046 (Revised 9/11/96) Page 3 <br />A SITE #G�L����OL'7JPROJECT <br />CONTACT & TELEPHONE # ajZ_ Ji Vj<5Z"CILITY <br />NAME0�PHONEDRESSOSS <br />f <br />STREETNER/OPERATOR <br />,, <br />JC/\/'�. / / GO�'C <br />PHONE #/' 7 .0 <br />ZLiI% / C 35 G %J 2i <br />C <br />CONTRACTOR NAME n i �' L';�; j T'� C.-� 10 A' GZ� <br />PHONE # 4S / _ ; Jr 9Z ZcF! <br />0 <br />N <br />CONTRACTOR ADDRESS%'GG,.L..,k�:rl�nic FIZ13 S:GC-f_^TCJ %7 Z1 <br />CA LIC # 7 % % 11 <br />CLASS A g, rlaL- <br />T <br />R <br />INSURER 67A TC LV A) 7 ?C•. 3:')( %y'7 y S. A CA c? 7- c, <br />I WORK -COMP.# <br />A <br />C <br />FIRE DISTRICT �� R("f��� ����%,�/� j <br />PERMIT # <br />O <br />LABORATORY NAME S;OAA,6,!E� ,=k(gGy7/ <br />PHONE 4 91,6 1 36z._•s�q¢ 7 <br />R <br />ri <br />SAMPLING FIRM Lj(%✓/,�C��JG'�7J%7'?-'`- PHONE #( <br />4i 575 =c ZL Z) <br />IIIIIIIIIIIiM IIIIIIIIIIIIIII <br />T NI ID # TANK 512E EMICAL STORED CURRENTLY/PREVIOUSLY DA UST INSTALLED <br />T <br />4/ <br />39- - <br />T <br />_ <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />- <br />39-6-1- <br />_ <br />39- - <br />39- <br />I111 Iilllllli�Jl IIS I I II III II Illl�lliillilliil II 1111111111111111111111111 11 II I I 11111111111 <br />-11111 <br />P 39- <br />L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br />a9-a-3/s�-�� 1 <br />A 1 (. CONDITIONS BELOW AND/OR ON ATTACHMENT) /� j/J/ <br />N i/U <br />7 <br />PLAN REVIEWER'S NAME, GATE C <br />i <br />1111111111I1111111111111111111111111111111111111111111IIIII1111111111111111IIIIillllllllllllllllllliillllllllll(IIIIIIIIIIIII <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: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOKIWHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF LIFORNIA.D CONTRACTOR'S HIRING OR SUBCONTRACTING 916MATURE CERTIFIES THE POLLOUINOE <br />"I CERTIFY THAT IN THE PERFORMANCE OF TH 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 / -"Gly DATE <br />CONDITION(S): �-, /O G1/Yl /YJ tf011,Lfi1'J <br />EH 23 046 (Revised 9/11/96) Page 3 <br />