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t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR P ERMAN ENTiTEMPORARY 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 /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE S (- C PROJECT CONTACT C:;'1 T j l A PHONE# `1 v t-1 -tl:L •C+ <br /> FACILITY NAME pG ►'-�C- 61<-.L-L— PHONE# r — 1 <br /> ADDRESS 4 c)31 4'wll <br /> CROSS STREET <br /> OWNER OPERATOR L,C, v u�i�YJ^ PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEPHONE# <br /> CONTRACTOR ADDRESS CA LIC# CLASS <br /> INSURER WORKER COMP`# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME c; COUNTY zb <br /> SAMPLING FIRM PHONE # rl LS S $ - �f S <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- '�c�t �.' �cf�r <br /> 39- <br /> 39- <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 AGENT'S 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 BECOMP 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.I SHALL EMPLOY PERSONS SUBJECT 7O <br /> WORKER'S COMP)ENSATION LAWS OF CALIFORNIA.' <br /> APPLICANT'S SIGNATURE TITLE DATE <br /> ❑ APPROVED ❑ APPROVED 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 /> EH 23 046(REVISED 08113199) Page 3 <br />