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SAN Jr QUIN COUNTY PUBLIC HEALTH cRVICES <br /> `'ENVIRONMENTAL HEALTH DIVISRSN <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE )i� CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CAU.0000 SLJ 16,5 PROJECT CONTACT 1 PHONE# S' oPS 41 36/ <br /> FACILITY NAME ,�J - O� h? PHONE# <br /> ADDRESS Q Q .S'• A) 44. At, ,AI& I a7 <br /> CROSS STREET T{j �oi7D <br /> OWNER OPERATOR PHONE#-O/-15? ig <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE#TA L <br /> CONTRACTOR ADDRESS E• CA LIC# CLASS C A <br /> INSURER G' WORKER COMP# W C /90.3'70 <br /> FIRE DISTRICT PERMIT# Al ;0. <br /> LABORATORYNAME ,te,'AIAV-44COUNTYSAIL� U PHONE# 9416 13 i<5' <br /> SAMPLING FIRM h I-16AWL PHONE # zo <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- jcjcr3 - 05 IZr000 /✓ !/GT 17 <br /> 39- 19 91 - 11 12 000 S� <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 LICENSED 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" <br /> APPLICANTS SIGNATURETITLE XJ l• DATE,/d'0.9,9 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE Io <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> a- e4' s•2t. '4 . <br /> EH 23 046(REVISED 08/13/99) Page 3 <br />