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ENVIIM HEALTH DIVISION <br /> P <br /> APPLICAT� F]��{I)1DERGROUND TANK CLOSURE PERMIT / GV0, <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABAN�DJO�NpMEINI IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FRO � (� y ' AIOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> PERMI ElRl\! S w-E)VVw&fm FER7 <br /> T pp_ <br /> REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE Ay �(L wpies ^ <br /> EPA SITE # C.>� ! DpCx'��6 3/�+ PROJECT CONTACT 8 TELEPHONE <br /> F FACILITY NAME BREA PHONE # �¢-2732 <br /> C ADDRESS ZOD/ ('Ad 95240 <br /> L CROSS STREET Cwe T <br /> I /� T ��7� <br /> T OWNER/OPERATOR /274, �� OF PHONE # <br /> Y PORCRSM cD, wFsT ce,4Noj7n A 9549/ 916- 372-7MS <br /> C CONTRACTOR NAME SE1.c PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESSe GS B CA LIC # CLASS <br /> R INSURER �LF-�USviP�/ yPTyryfGT/O.� IRtWN e(re WORK.COMP.# -664 -01 <br /> A r <br /> C FIRE DISTRICT /��� C l " D PERMIT # <br /> T <br /> 0 LABORATORY NAME � /, PHONE # 2,09--f 7!0 1635 <br /> R <br /> SAMPLING FIRM PHONE # -¢7�'1/a,�S <br /> III II 1111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 2132- -/ 2500 61S LWLEA S 3/ <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L _ APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE gTACHMN( THC ) <br /> N PLAN REVIEWERS NAME .�I�// / `C- /fI GI DATE s <br /> hhl <br /> III II III II III II II III II III II III Ii 11111111111111111 ill1111111111111111111lli 11111111111111111ll ll Ill l II l III 11111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY 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: T / Q�Aj <br /> TITLE DATE T/ <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />