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SAN JOAC ' 'IN COUNTY PUBLIC HEALTH SEP`/ICES / �C£ <br /> ENvlRONMENTAL HEALTH DIVISION✓.► a <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 /> ,,)�EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#L M-00DO 25 PROJECT CONTACT - PHONE# \� �-^- 2' ;A ' <br /> FACILITY NAME A 471PHONE# <br /> ADDRESS S T '— L k E " <br /> CROSS STREET <br /> OWNEROPERATORF C�� '� PHONE ,i - 5a( <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME WN PHONE# 2.(Jti <br /> CONTRACTOR ADDRESS t; S; ,t iJ -S l G i I c- A I CLASS <br /> INSURER ) N I WORKER COMP# <br /> FIREDISTRICT -" PERMIT# <br /> LABORATORY NAME COUNTY PHONE /- <br /> SAMPLING FIRM ` - PHONE <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 139- �� � � - <br /> 39- � 1 <br /> 39- ef - <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,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE ���� TITLE�t IV Fyl� O(�����h DATELI <br /> ❑ APPROVED 9,A�/}PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> ✓�`��., (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME��/(�.�-�,^ DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> leg <br /> ad it <br /> (ate <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />