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v. yj <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION.FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITENIPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 HAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT w r- PHONE# .201 -'17- BOO <br /> FACILITY NAME ar ,e^4r r p IPHONE# <br /> ADDRESS I.1100 5.Ovt(, 176rlal P-OC L A trIIJ25330 <br /> CROSS STREET L&__LlL <br /> OWNEROPERATOR cargc^4er Co. PHONE#2O -?F7 tlbY1� <br /> I <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME V4(ueJ eA!j;neerioq I PHONE# <br /> CONTRACTOR ADDRESS erne MCA `j QCA LIC#t SII I`atZ CLASS 14QZ <br /> INSURER C,+t Fv^k WORKERCOMP­_- 1 3`OZ- Oa0 Y 7L <br /> FIREDISTRICT 1.a Manfe[0. PERMIT# <br /> LABORATORY NAME G b. Ak I c a COUNTYLa cleS PHONE#S6Z-2-1 - �OO <br /> SAMPLING FIRM cc r;nvi r m 4n�r. ti PHONE # g0 K 0(. <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- '0�' 10 00 0 D;eS e{ «$rJ <br /> I j <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- <br /> 39- <br /> 39- <br /> 39- <br /> 3S_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 AGENT'S 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 /> APPLICANT'S SIGNATURE YZ � �- TITLE /' DATE 03 <br /> ❑ APPROVED APPROVED WITH CONDITIONS ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) h <br /> PLAN REVIEWER'S NAME — DATE U v <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> Ll <br /> I <br /> t <br /> EH 23 046(REVISED 08/13199) Page 3 <br /> I <br />