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r + , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR 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 /> _x REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # `T) 5X2, 971 8S6 PROJECT CONTACT 8 TELEPHONE # Tar <br /> F FACILITY NAME c' (,(,m PHONE #ruffF 5fel- 6(.3 <br /> A /� <br /> ADDRESS ZZ^L Ca rz <br /> I 9S'y to <br /> cr <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATORPHONE # <br /> Y I ca 4r ( W5 549 <br /> C CONTRACTOR NAME SE111CU PHONE # <br /> 0 (209) 524-9653 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. Modesto, CA 95351 CA LIC # 449864 CLASS A B C61/D40 <br /> T <br /> R INSURER Calcomp Insurance Company WORK.COMP.# W964137662 <br /> A t� e/ <br /> C FIRE DISTRICT R.) bu jr-L Y68-T1; p 0 PERMIT # <br /> T <br /> 0 LABORATORY NAME CieoanalytiCal Lab COUNTY Stanislaus PHONE # (209) 572-0900 <br /> R <br /> SAMPLING FIRM Geoanal.ytical Lab PHONE # (209) 572-0900 <br /> 11111111111!11111111111111 1111 <br /> TANK 10 # TANK SIZE CHEMLCALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- /,9, 0670 L%Aw-.G/ . <br /> T 39- y K hilt _ ilbasm tato <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Mill I illllllllllllll I I II IIII 111111 II IIIIIIIIIIIIiI IIIIIIIIIIIIIIIIIlIII 111111 IIIIIIIIIIIIIIIIillllilllllllll <br /> L yAPPROVEDAPPROVED WITH CONOITION(S) DISAPPROVED <br /> ( E <br /> A E COND T BELOW ANO/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAMI'� � - � Q ��-(__. DATE <br /> 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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 COMPENSAT ON LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERfO NLE OF INE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFO IA." � , <br /> APPLICANT'S SIGNATURE: C- TITLE •NNNN��,� DATE O p- <br /> -Z <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> EH 23 046 (Revised 7/10/96) Page 3 <br />