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SAN JOAO�d COUNTY PUBLIC HEALTH SER"'CES <br /> EN RONMENTAL HEALTH DIVISION 1-./ <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR OF UNDERGROUND <br /> RDOUS <br /> STORAGE TANK(S)EXPIRES 90 DAYSOFROM THE APPROVAL DATE. DO NOT WRITE RARY CLOSURE OR ABANDONMENT IN PLACE N ANY SHADED AREAS. IN KATE PE M TATYP S I <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION PHONE# oR- — ) <br /> EPA SITE1�`{l I��I`��S( PROJECT CONTACT PHONE# <br /> FACILITY NAME r <br /> ADDRESS a <br /> CROSS STI PHONE# <br /> OWNER OPERATOR <br /> CONTRACTOR INFORMATION <br /> PHONE# A'L <br /> CONTRACTOR NAME CA LIC# O CLASS <br /> CONTRACTOR ADDRESS WORKER COM <br /> INSURER kA�Q I CA a ��U T I u/`-- <br /> PERMIT# OO <br /> FIRE DISTRICT COUNTY PHONE# q� <br /> LABORATORY NAME <br /> SAMPLING FIR IZ I Q (}T �lS\RtrA� TA �J ,,_ <br /> J TANK INFORMATION DATEINSTALLED <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) <br /> 39- LAn <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> DACOUNTY <br /> TTIAFL <br /> ULES AND <br /> MUST <br /> SORMALL <br /> WORK IN ORVICES. OWNEROR LICNSED AGENTS SIGNATURE CERTIFIES THE OLOWING, 'I <br /> REGULATIONS AN COUNTY PUBLIC SE <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 THE FOLD OWING. *1 CERTIFYTHAT N THE PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUEOR'S HIRING OR D. SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS 'CALIFORNIA.' <br /> TITLE � l DATA�—o <br /> APPLICANTS SIGNATURE <br /> ❑ APPROVED <br /> PPROVED WITH CONDITION ❑ DISAPPROVED <br /> (SEE CONDII NS LOWAN /OR ON TTACHME <br /> jDATE <br /> PLAN REVIEWER'S NAME <br /> ANY DEVIATIONS FROM THIS APPLICATI MUST BE U MI D TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> T <br /> Page 3 <br /> EH 23 046(REVISED U01 101911 _ <br />