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SAN JOAQUIN COUN I Y rUOLIU nr_r+L- I FT <br />F 'VIRONMENTAL HEALTH DIVISIO' <br />APPLICATION FOR-ONDERGROUND STORAGE TANK—CLOSURE PERMIT <br />THIS PERMIT NMENT <br />ERGROUND <br />STORAGE TANK(S) EXPIRES NS 90 DAYS FROM THE APPROVAL DATE. IPLACE <br />DO NOTWRI EN ANY SDHAZARDOUS <br />SHADED AREAS.INDICATE PERMIT TYPE: <br />❑ REMOVAL ❑ TEMPORARY CLOSURE E( CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMA i IUN <br />CONTRACTOR INFORMATION <br />EPA SITE 0 <br />PROJECT CONTACT / L % <br />PHONE# <br />FACILITY NAME <br />r-7 2 S%Tt %7 ''L <br />PHONE # /V f} <br />ADDRESS <br />/'7d / T ✓tS .+ '� <br />J 7-1 s 6tj T CA LIC It <br />CROSS STREET <br />FY -67f, N o <br />A/ ' <br />OWNER OPERATOR <br />CI i s G <br />PHONE # <br />TANK INFORMATION <br />TANK ID # <br />CONTRACTOR INFORMATION <br />39- I,1O <br />CONTRACTORNAMEP <br />39- <br />'7CZ� <br />39- <br />IPHONE# 6 <br />CONTRACTOR ADDRESS <br />q0D iJ0F_Ti— <br />J 7-1 s 6tj T CA LIC It <br />) ZZ? CLASS r4 7 <br />INSURER <br />WORKERCOMP# <br />FIRE DISTRICT "t�c 11'—'{U /`/ <br />I PERMIT # <br />LABORATORY NAME <br />COUNTY S <br />PHONE # 9 G' - <br />SAMPLING FIRM <br />.z C; S / s.S <br />PHONE Y <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATEINSTALLED <br />39- I,1O <br />Li i�/IPIJU <br />39- <br />39- <br />39- <br />39- <br />39 - <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES. STATE LAWS. FEDERAL LAWS. AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS 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 BECOME 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. 1 SHALL EMPLOY PERSONS SUBJECT70 <br />WORKER'S COMPENSATION LAWS OF GLIFORNIA' <br />APPLICANTS SIGNATURE " "�iO.(il.c J//���i.I-!(( TITLE -� Zi DATE <br />EIAPPROVED XAPPROVED WITH CONDITION(S) El DISAPPROVED <br />u <br />CONDITIONS BELOW AON ATTACHIMENT) <br />PLAN REVIEWER'S NAME DAT&_i <br />q <br />ANY DEVIATIONS FROMI THIS APPUCATIONBE • TO EHD FOR APPROVAL• • COMMENCING WORK.4 <br />CONDITIONS - <br />02 <br />I <br />3 Ooh (REVISED 10/19/98) Page <br />