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09/L3/2001 T1IU 14:53 FAX 2083433 STC EHD � 0007/012 <br /> 1KN V'YRONIVMENTAE HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PFRMI'-FOR PERMANCNTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARCOUS SUBSTANCES <br /> STORAGE'Gl K(S)WIRES 90 DAYS FROM THE APPROVAL DATE, OC NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPI-- <br /> Q REMOVAL ❑TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACIL.I°Ty`.-.OR:MATIO.N. <br /> EPA SITE ONTACT C P15 A 1}I SGU PMONEi! 2 - x 3�� <br /> FACILFTYN4M= SRSr CA4kr-02NIA, QAS L. Ck, <br /> ADDRESS JL!q-2 'P40tT:%C AVG, 5TPCI-T hj , CA g 5207 <br /> CROSS STHEET P-I VAS'A, - -- <br /> OWNER c+eftk 9R $QST c L I b N A P13 <br /> .0ONTRACTQ1RjNFQ:atUTAT�o�v <br /> CCNTRACTOR NAME aIFO\m PHONE# <br /> CONTRACTOR ADDRESS r wavl �lI2.'t" 'f.� CA LIC# CLASS w}}ya,� <br /> INSURER _Co WO KE104 R COMPN I { <br /> FIRE DISTRICT PERMIT# <br /> LA00RATO 2Y NAME Lokra.ti2r COUNTY <br /> SAMPLING 'IRM PHONE# <br /> TANK-INFOR-MATION <br /> TANK 10# TANK SIZE I TANK CONTENTSPRESENT& PAST DATE INSTALLCO <br /> 39-��C' lob I'2" 0b0 [fiesenl';�M PdL�f~; ul�� �I a <br /> 39- <br /> 3,9= <br /> 39� <br /> APPLICANT N UST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATION 3 OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSVEO,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER i.S TO BECOME SUI3JEC1' TOW KER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE I;ERTIFIES THE FOLLOWING, C TIFY THAT:N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM[T IS ISSUED, I SHALL <br /> EMPLOY PER IONS SUBJECTTOVV R' CO ENSATION 1JI FORNIA' <br /> APPLICANT'i SIGNATURE TITLE-re 51( Q __ DATE <br /> ❑ APPROVED XAPPROVI-D V'III;TH-' b17ION(S) fl 1718APPROV�D <br /> ;SEE ONDIT[ONS DELOWANWOR'ON ATTACHMENT), <br /> PLAN REVtEJVERrS NAME DATE <br /> ANY DEVIATIONS F 4R M TH18 APPLICATION MUST E10 S, $fN TLI I.' <br /> Tp;�TQ 9H D FOR APPROVAL PRIOR TO COMLYIENGIN,13;411,ORK. <br /> CONbiTIONS; <br /> Ell 23 046 (Revised 11/21/06) 3 <br />