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� s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> 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 # CA D 9 61 b�39(C"3 <br /> PROJECT CONTACT & TELEPHONE # DLV 9 -I <br /> F FACILITY NAME � b$' PHONE # 2Q -33- B3 <br /> A NE <br /> C ADDRESS "u0 p Lo d, <br /> 1 <br /> L CROSS STREET C <br /> I <br /> T OWNER/OPERATOR W)ou . Cr " PHONE # <br /> Y USA 0Lir06 Core 3olol A cA BIS -SL,S- o <br /> C CONTRACTOR NAME " O M O Mem PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS Z ?L. _T CA LIC # CLASS <br /> T <br /> R INSURER SE2,.� IN3. to Sti Ta.J WORK.COMP.#SELf <br /> A <br /> C FIRE DISTRICT C, j PERMIT # <br /> T <br /> 0 LABORATORY NAME 'Sp/JQ„GiFYL COUNTY SpK.?A.iy.r_ PHONE # qil,_33 Z- 'S <br /> R SAMPLING FIRM Cj F'} N Elf". (ame- $$y 9, CIrou j k+ari5 k4t3 [t9O PHONE #S6 Q �Z. <br /> I(o- 3 -7( ,i r <br /> nuunumnn�lnfuimn <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 0 .600 rnAeSo& ;,.IE I.��W-AJMr,a <br /> T 39- 2.1 n0 p <br /> A 39- - 111090 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A n (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAME I-j� , ��_,4,e T DATE <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." Q <br /> APPLICANT'S SIGNATURE: �^ TITLE PRq,�, ' C0D.4.,d4 �IDATE -7-V-1-97 <br /> bao1 IC . 1-D F1 CW <br /> CONDITIONN: / <br /> r) /l <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />