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rI-curve P. 6 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERFAANENT17EMPORARY CLOSURE OR ABANDONMENT IN PLACE OK UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EDIFIRES SO DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> .REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SRE It (,jb� I PROJECT CONTACT E L,AI PHKONE# �a 3 <br /> FACILITY NAME 4 p s GSE A . <br /> ADDRESS w PDAD <br /> CROSS STREET Lmg-kl-�mil-ti <br /> OWNER OPERATOR Q ;,HONE• <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME1 PHONE s <br /> CONTRACTOR ADDRESS LI V CA UC f CLASS <br /> INSURER WORKER COMPS NIA <br /> FIRE DISTRICT PERMIT <br /> LABORATORY NAME COUNTY ONE O 6 <br /> SAMPUNG FIRM PHONE Y <br /> TANK INFORMATION <br /> TANK IDK TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- i L <br /> 39- 50FAbcf-9 <br /> 39- <br /> 39- <br /> 39- <br /> 139- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WRH SW JOAQUIN COUNTY ORDINANCES.STATE LAWS. FEDERAL LAWS.AND RULES ANO <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLCVANG: '1 <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 ViORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTORS HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> SHE FOLLOWING: 'I CERTIFY THAT iN THE PERFORMANCE OF THE V40RK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CAUFORNN.' ((��VS/KJ L35 <br /> APPUCANT'5 SIGNATURE �""'� \ TITLE p /{'l/�jUa{-6,EL. DATE <br /> I IST>„ 5 <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONOMONS BELOW AO O/OR ON ATTACHMENT) <br /> L C3 <br /> PLAN REVIEWER'S NAMEe / / �l C(J DATE./ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SU8MITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK <br /> CONDITIONS: <br /> c, -. <br /> � C <br /> aw r neA oc,ilc.n ,N,aQm o....z <br />