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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMTT <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _3 REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # 64LT 1X7, L171 8S6 1 PROJECT CONTACT & TELEPHONE # -rfw j (w/ ,SL(1-16,�.;- - <br /> F FACILITY NAME �y(,(,h�.(� ,L PHONE #(Z&9 57fei,6(7)� <br /> A /^ /ter <br /> ` ADDRESS ZZZ 00 U /�•r 4q r 9s''y ee b <br /> L CROSS STREET <br /> I <br /> YOWNER/OPERATOR &U. J - /1 PHONE S q q-` 1 3 1 <br /> C CONTRACTOR NAME J.g,i� t ll� PHONE # (209) 5244-9653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. [,iCd2St0, 351 LIC # 449864 CLASS A,B,C61/D40 <br /> T <br /> R INSURER Calcomp Insurance Company WORK-COMP•#W964137662 <br /> A <br /> C FIRE DISTRICT fLl l3(,( 11r-� PERMIT # <br /> T <br /> 0 LABORATORY NAME Geoenalytical I COON Stanislaus PHONE # (209) 572-0900 <br /> R <br /> SAMPLING FIRM lyticTa)7 I PHONE # (209) 572-0900 <br /> IIIIIIIIIIIIIIIIIIIIIillllll <br /> TANK ID # TANKS CHEMLCALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- l7 O 4,G{ . <br /> T 39- G 0.Ty L t.tQ j <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> IIIII111111 I III I I Illilllllilill IIIIIIilllliillllllllll IIIIIIIIIII 111111 1111111 I 111111 � <br /> P <br /> L APPROVED APPROVED WITH CCNOITION(S) DISAPPROVED <br /> A (SE. CONDIT DN BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <br /> Illiilllilllliilllll111111111111111111111111111111111111111111111111111111111111111111111111111fill 111IIII1111111111111111111 <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 ANY 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 /> "I CERTIFY THAT IN THE PERF0 NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CALIFO IA." �1 <br /> APPLICANT'S SIGNATURE: fi4C- (-:' TITLE V u. (amu DATE $-Z7-5'7 <br /> 61 P <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> �- &44V (ne� SArrrQ(r^tet L.:� A 5 <br /> EH 23 046 (Revised 7/10/96) Page 3 <br />