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pAYMENT <br />DECEIVED <br />SEP 2 81998 <br />3: N JOAOUIN COUN rV <br />PUBLIC NEALtH SERVICES <br />ENVIRONARENTAL HEALTH DIVISION <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X _ REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PUCE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE At Cf�WQL 1 �(p <br />PROJECT CONTACT TELEPHONE r Nl jL YUC,G.1 IZ�Z?z,-4"�c <br />F <br />__i <br />FACILITY NAME �U ��N I"flJ r,l- <br />�t3\OAA <br />PHONE N 4 93� Q7[U/ <br />A <br />C <br />aooaess L/51$ E fp M E)Z S M tTti�l' -mcjcT N <br />t <br />L <br />CROSS STREET C -�� k,e-'I <br />7 <br />OWNER/OPERATOR <br />MArc SuSAr� �jtZ <br />PHONE 0-2 9 2/ O ycL� <br />lI J <br />Y <br />( w <br />C <br />CONTRACTOR NAMETial N(]NN-INC-P, NL <br />PHONE S 20q 3328JI5 <br />N <br />CONTRACTOR ADDRESS I ( ( '5 B LK D i A�QN Q �y <br />G L!C r (C ���{ (Q L <br />CUSS <br />TLARK. <br />R <br />r <br />INSURER CSr'js t.ArVG-z CO <br />L <br />COMPO <br />A <br />C <br />FIRE DISTRICT WAn--rZ_`o0 M0 W,A-pf} PERMIT X <br />0 <br />�j <br />LABORATORY NAME PHONE # (,51 G� ��'(3 �Gi �.(� <br />R <br />\ <br />SAMPLINGFIRMx111. f�hJLf( i�M '�L I NL PHONE a (01-15�-Lg3 /c L7O0 <br />TANK ID It TANK SIZE CHEMICALS STORED WRRENTLT/PREVIOUSLY DA J^ S�INSTALLED <br />39- S� O G A'LL C�ASJW /1J� - <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />in un i in un ullill 1111111111111111111P <br />L APPROVED APPROVED WITH CONDITION(S) ON(S) _ DISAPPROVED <br />_ <br />OND <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />DATE <br />j N PLAN REVIEWERS NAME <br />APPLICANT MUST PERFORM ALL WORK IN ACC010ANCE WITH SAM JOAOIIIN COUNT? ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />CERTIFIES THE FOLLCSIING:I <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE <br />. CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 7X[S PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />TITLENCjJ FLT Nl A'rj"tC LDATE I l <br />APPLICANT'S SIGNATURE*; - U'` <br />EH 23 046 (Revised 7/10/92) Page 3 <br />