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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />❑ REMOVAL TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />CONTRACTOR NAME <br />EPA SITE# In i90 <br />i PROJECT CONTACT SUKNW%i✓ (^!Z 5l <br />PHONEI( jJ 9-5-4- IS-Li <br />FACILITY NAME <br />WS"Tf Z"7flS>lmf}RT <br />PHONE tl-D <br />ADDRESS 2=L4 <br />'A W, R O; '1-✓��1 <br />SAMPLING FIRM <br />CROSS STREET <br />rovArlio P <br />OWNER OPERATOR <br />'LI j)44'jtVr9Irg <br />PHONE d 2-1�11-' Cl SLI ->S-LIQ <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME <br />P - m ST ion JD.Q.�/;: u PHONE # <br />CONTRACTOR ADDRESS 324-7 La YiShr%f 'RX ob° CA LIC# 856771 CLASS <br />INSURER <br />WORKER COMP# ST -07,f TW-TiW i tree <br />FIRE DISTRICT G('rr <br />OC1(TOAI PERM IT# <br />I <br />LABORATORY NAME <br />/0 COUNTY S .TC PHONE # <br />SAMPLING FIRM <br />e ti'l Pl IPHONE# <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS PRESENT AND PAST <br />DATE INSTALLED <br />39- Sn7 9 6 6"000 <br />4-4Ally <br />39- 5all%F7 lo,vc>o 9.4a <br />(gg2r <br />39- <br />/99T <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br />FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br />A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br />SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNAtRE LE TE <br />❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 10/30/12) <br />