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11 <br />r <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDE400M TANK CLOSURE PERMIT J U L 25 19,91 <br />C \ LFj�iFl <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IM PLACE OF UNDEROROUIID NAZAROtAt4 SUBSTfA11Nti si(19i1Arfl'ECl`k_� G <br />THIS PERMIT EXPIRES 90 DAYS FROM TH§ APPROVAL DATE. DO NOT KITE IN ANY SHADED AREAS. INDICATE PERIRtRAP[+lEC <br />V REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH ?i 0(,6 (R" 2/8/91) Ft� � v be9R 3 I <br />'feurt)-d- <br />; n � ��',•,�'/�"may <br />n e.��o - ,o w� n c�-Pa--C_yLg�(-A_V_� wp�Q„vI l/'a PnI U <br />4v`:� 6D S'l, co , b I I doto lkr, <br />EPA SIT. .r_. ;. <br />PROJECT [(INTACT R TELEPHONER <br />F <br />FACILITY NAME /._: R <br />L�I <br />PHONE l <br />� <br />II C3 ,_�(U3s ---- <br />C <br />I <br />ADDRESS 3.J '�� L3, Ck, '1J�c,L� -- <br />— <br />L <br />CROSS SIRF.ET <br />I <br />T <br />–. <br />OWNER/OPERATOR <br />PHONE I <br />Y <br />C <br />CONTRACTOR NAME <br />PHONE RI,_`tN <br />CONTRACTOR ADDRESS t ,--C <br />I Z bck , 0 CLASS - <br />fCAJ <br />i <br />tV <br />R <br />INSURFR 'T- ,L S,:iV� <br />WORK.COMP.IW` C7`6L �E;. <br />A <br />f, _ <br />_-___ <br />C <br />FIRE DISTRICT 1 _ <br />PERMIT k <br />0 <br />LABORATORY NAM <br />L �NA�v c <br />1 A� DHOHE O� (I_ S� <br />1� i 012 <br />SAMPLING FIRM C(,`.L'\C--,:�C\C% (-L�,7Tic 4- �Ur\ <br />PHONE, <br />_—_- <br />IIIIIIIIIIIIIIIIIIIII'IIIIIII�J <br />TANK ID I TANK SIZE <br />CHEMICALS STORED CIRREX � /PREVIOUSLY DATE UST INSTALLED <br />f1 I" _ <br />39-_ ri,�V� cuo E:iAcU-On <br />A <br />IIIIIIIIII <br />IIIIIIIIIIIIIIIIIIiIIliilllllllllllllll Iillllllllllllllllli�� <br />P <br />I <br />A <br />����illl��lllil�ll�lll��l�llll ������������������ <br />u APPROVED APPROVEb WITH C IIDITIdI(S) ,__ Ot SAPPROVEO <br />(SEE TT 1M NT WITH Cf1101itdIS) � �� �/ <br />M <br />FLAN RF.VIEUrPS NAM _ W V V <br />I II II I II II III II II II I II III II ill 11 III II III it III II II III II II <br />GATE _ <br />II III II I'I'I II III II III II III II II III II III I III II I II II III II iil <br />APPLICANT <br />MUST PERFORM ALL WORK IN 0.CCORDANCE KITH SAN JOAOUIN <br />T'I ORD (IMNCES, STATE lAW4, AND RULES AND REGULATIONS OF <br />SAN <br />JOAOUIN COLRITv PI IML IC HEALTH SERVICES. OWNER OR LICENSED AOE 7'! SIGNATURE CERTi F1E4 THE EIxLtA(I NG: "I CERTIFY THAT IN <br />TLE <br />PERFORMANCE OF THE WORK FOR WHICH TRIS PERMIT IS ISSUED, 1 S <br />LL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS Of CALIFORNIA." CONTRACT OS HIRING OR SUBCONTRACTING SIGNATURE CERTI)IES THE FOLLOWING! <br />"I <br />CERTIFY YHAt IN THE PERtOP,MAN THE WORK FOR WHICH THIS MIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFOR <br />� <br />j DATE <br />PopLlf-nVT'S SIGNATURE! <br />TITLE ( <br />EH ?i 0(,6 (R" 2/8/91) Ft� � v be9R 3 I <br />'feurt)-d- <br />; n � ��',•,�'/�"may <br />n e.��o - ,o w� n c�-Pa--C_yLg�(-A_V_� wp�Q„vI l/'a PnI U <br />4v`:� 6D S'l, co , b I I doto lkr, <br />