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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANKLOSU E PtRMtT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDE R6GND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADE"REAS. INDI"eERMIT TYPE: <br /> 9 <br /> Gd REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION ` <br /> EPA SITE#C' 86 7 PROJECT CONTACT DAAJA -514A) M A I PHONE# 209 q4-1-2 <br /> FACILITY NAME C LA K P A R.L P,0 LA s FE PHONE# ZB9 94 <br /> ADDRESS 3/2 ST F 1z 'T STI <br /> CROSS STREET QRB A 'rP-Lr. T— <br /> OWNER OPERATOR LLQ C-t4AtJ LRP-- 1jQ"PMTW O41JN2 e PHONE# Z 3- <br /> CONTRACTOR INFORMATIONAx Af61-1113 <br /> CONTRACTOR NAME C L UAJV A) L I L .J- C. PHONE# 2-09 7 -/O <br /> CONTRACTOR ADDRESS +009 L s CA LIC# 6f3O TZ CLASS A N <br /> INSURER 5`r. PA UWORKER COMP# 31—j 4 — -1 <br /> FIRE DISTRICT ST C.Ic C PERMIT# <br /> LABORATORY NAME 9-E7C I S UIk.U- ac f COUNTY XIIII.SAAJ1041 PHONE# ()l -z--6997- <br /> SAMPLING FIRM PHONE #Ir — <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> illl4J0wN <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <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 PUBLIC HEALTH SERVICES. OWNER OR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.'I��JjI O G <br /> APPLICANTS SIGNATURE YGZ"'//�'!�W • TITLE STR-FF 6GeO6FSl- DATE 07 ?- <br /> 0 <br /> ❑ APPROVED gAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATES/.3- 9 7 <br /> ANY DEVIATIONS FROM THIS APPLJCATION MUST BES BMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> S— <br /> EH 23 046(REVISED 10119198) Page 3 <br />