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0 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT(fENIPORARY 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 CK,TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROTT CONTACT PHONE# q 2!57 n D <br /> FACILITY NAME 1 C- _ PHONE#q2S7 <br /> ADDRESS 41051 1)(AjrvA f4opo. StpGc-To+'1 I C4 C15205 <br /> CROSS STREET jn VX W I I u <br /> OWNER OPERATOR S {LfY1 PHONE# 8Z3 " <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# 74-7 6(,q <br /> CONTRACTOR ADDRESS tFk ) © CA LIC# '1'60 100 CLASS + <br /> INSURER 4jTATGCvM WORKER COMP: 7 <br /> FIRE DISTRICT 1 PERMIT# uPtln {} <br /> LABORATORY NAME AflA COUNTY A) PHONE# 4 <br /> SAMPLING FIRM AAAPHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9-39- <br /> 39- <br /> 39- <br /> 39- <br /> 39-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 1N SUCH A MANNER AS <br /> TO BEC MS SUBJECT TO WORKERS 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 TO <br /> WORKER'S COMPENSATION LAWS <br /> JOF�CALIFORNIA.• (? <br /> APPLICANT'S SIGNATURE^�,/1�4(11;C&.1 �)TITLE rC>a-P&iC!C4ftZL DATE <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED- <br /> - <br /> (SEE C4NDI710NS BELOW AND14R ON ATTACHMENT) <br /> r <br /> PLAN REVIEWER'S N._ �-��` - C� �I('c(� \ <br /> BATE I.% <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> l EH 23 046(REVISED 08113199) Page 3 <br />