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SAN JF'�r'11N COUNTY PUBLIC HEALTH GFRVICES <br /> ARONMENTAL HEALTH DIVISC <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE*LAI 0000Z,5W�2 PROJECT CONTACT I PHONE#t77,77 5- 77 G <br /> FACILITY NAME FAC I PHONE It <br /> ADDRESS ,, S Z — L 6Mh M N mt - <br /> CROSS STREET L7— N) S <br /> OWNER OPERATOR �_ `� ( b(\'J PHONE '10 - <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME -\ PHONE# 2,6 g - 7 <br /> CONTRACTOR ADDRESS o S 7 t k - '� C �— CA LIC#7 CLASS -N <br /> INSURERWORKER COMP# <br /> FIRE DISTRICT — -r F ' L_ �,� �' 1 Z PERMIT# <br /> LABORATORY NAME - COUNTY PHONE Cp ri - <br /> SAMPLING FIRM - PHONE ft - j J 0 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- ( 3 4ID2 -7 <br /> 39- I 7 - - - zA - <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 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. '1 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 T �` I'CALIFORNIA.' <br /> (\ <br /> APPLICANTS SIGNATURE I �i-'�./.I TITLE Ar tnl i TUi� (�j�)�)C� DATE U7 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> / - <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME f;J v' DATE I'° <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIO S' <br /> fz) -Cs CZvtS'�� <br /> EH 23 046(REVISED 10/19198) Page 3 <br />