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VAW Now <br /> 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 /> �(_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # e"I q0(/ ui'6 PROJECT CONTACT & TELEPHONE It `�(� _Gu,l •Fey,. (Z y7)3Z9-x}65'7, <br /> F FACILITY NAMErirt e.rPHONE # <br /> G15 <br /> C ADDRESS J11,50 $6#t &K-, <br /> I <br /> L CROSS STREET v, <br /> I <br /> T OWNE /OPERAT R PHONE # <br /> Y 1, L Lr (2tfi) <br /> C CONTRACTOR NAME J-�., PHONE # (209) 524-9653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. Modesto, CA 95351 DA LIG # 449864 CLASS A,B,C61/D40 <br /> T � <br /> R INSURER Calcomp Insurance Company uoRK.coMP.# w964137662 <br /> AY'y1�L {AODM <br /> C FIRE DISTRICT Lye, [Q I/5 F,u, fiL 0— 'A . 5JI-7;7 i D PERMIT # <br /> T <br /> 0 LABORATORY NAME Ceoanalytical Jab COUNTY Stanislaus PHONE # (209) 572-0900 <br /> R <br /> SAMPLING FIRM Geoanalytical Tab PHONE # (209) 572-0900 <br /> TANK ID # TANK SIZE CJIENICPLS STORED cLyyRRRENTLY/PREVIOUSLY GATE UST INSTALLED <br /> 39- " D l Do 644 I,ec2`ec1 Qa50lr _e- LG.[ ! <br /> T 39- Oa oce. <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 11 111 fill].11111[111111111111 FliTFii-i-flillillillilillifilliillillilI <br /> P <br /> L APPROVED ]X�` APPROVED WITH CONDITION(S) DISAPPROVED <br /> A CaCC CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 4—Y 7.f g=Q�� DATE <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI .' <br /> APPLICANT'S SIGNATURE: TITLE 1 <br /> M11A DATE <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> r1 n)* w o r K- bei Y) �- T�ivK e <br /> ® ASS <br /> EH Z3 04.6 (Revised 7/10/96) Page 3 <br />