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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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # )l`Q a �•;�l PROJECT CONTACT & TELEPHONE k J �. - / <br /> F FACILITY NAME PNONE <br /> i <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> T OWNER/OPERATORr PHONE <br /> 77 <br /> C CONTRACTOR NAME (9 fi.Sok " T/B PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC k � 1 CLASS <br /> T _ <br /> R INSURER �•� ,Y - WORK.COMP.# <br /> A <br /> C FIRE DISTRICT lei'0,90A, PERMIT # <br /> T <br /> 0 LABORATORY NAME - (,(7 y- PHONE It <br /> R <br /> SAMPLING FIRM PHONE # <br /> TANK ID # TANK 512E CHP ICALS STORED CURRENTLY/PREVIOUSLY DATE UST/INSTALLED <br /> T 39- _ <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L Y APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AN;RE�GULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 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 CALIFORNIA.- <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> t47- a to ad k+ R-ri+'n o P zo L-6 //W(DS,0:5 C5 Alljk <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />