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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IM PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FAC IL II <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO 901 WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW! <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE NC R Y 1 i PROJECT CONTACT i TELEPHONE N <br /> F FACILITY NAME + v ,CAIJ. PHONE N <br /> A /Ah AnCl ^�oI, /ih <br /> ^ <br /> C ADDRESS "ZY ( V `(� �1, <br /> I <br /> L CROSS STREET > (7 <br /> 1 <br /> 1 OWNER/OPERATOR t,1 PHONE N <br /> Y <br /> C CONTRACTOR NAME <br /> 0 l PHONE N o_ Li_`'. <br /> N CONTRACTOR ADDRESS ' �-` '� J �F, CA LIC tl L (' CLASS <br /> RINSURER C� ( WORK.COMP.tl �� ? ^�'-7 <br /> A <br /> C FIRE DISTRICT Gn rt 4 w PERMIT N <br /> T /'1 PHONE N <br /> 0 LABORATORY NAME C <br /> R —' <br /> La L <br /> SAMPLING FIRM PHONE N <br /> 111111111111111111 X11111111111 <br /> iaur .r [ANK 61ZF CNENI CAIS *ORLD n]R RF MTLY/PREVIOUSLY GATE UST INSTALLED <br /> ar`;eSeol 14 t4 1KALp IA <br /> T 39- - �T <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- 7 7rT T 7'1r 7' 7Y 7 �77Y77FY YF� <br /> P l iiinmlrrrTrr{Ilmrrlm 11 In mll uffluf mmmffl111111111111{limlll <br /> L _ APPROVED APPROVED WITH ODNOITIOU14 _ DISAPPROVED <br /> A (SEE ATTACHMEN S) �y <br /> N PLAN REVIEWERS NAME DATE <br /> II II IIIIIIIIIIII1111ITTITTTTT 11II1(TTTmfTifii11[111IT, mTil <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, 1 SMALL 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 TTIF WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT 10 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: ` �I .R r �✓l^.A� 117LE DATE .,Q� <br /> Ell 23 046 (Rcv 2/6/91) it PABo 3 <br /> (Rev 4/8/91) <br />