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ENVIRONMENTAL HEALTH DEPAR-f-MEN-T <br /> SANJOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT(TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE #N ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> 4REMOVAL 0 TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> -7- <br /> EPA SITE# PROJECT CONTACT <br /> I PZNE9 67 <br /> FACILITY NAME t-ttu?0 PHONE# <br /> ADDRESS j'91> 4-', (212 Z,6k.-.3 �m dz-Z 2,7, 2 <br /> CROSS STREET /V "(0 <br /> -5 t <br /> OWNER OPERATOR :7-LJ J1 CioL 11 6,9 0 0 tit I 60,� t PHONE,# 6-(5' <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME /v I^I rviA rvLjl,f,�t 3-p-r v c---d E o <br /> CONTRACTOR ADDRESS 3 1 5-0 eq 1-hi V," of P4 g q Y w a • 64 CA Lic# 57 CLASS AjP,,czi)CV CCut-e-6) <br /> INSURER IVCIIJ64 ;,- l V, Co VVCRKERCOMP# -S Iq&, <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NACOUNTY Z41 1:4 FIVCI� PHONE# <br /> SAMPLING FIRM Aw'jly,4 gi PHONE <br /> TANK INFORMATION <br /> TANK ID# ;?nl<SIZE I TANK CONTENTS(PRESENT AND PAST) DATE INSTALLED <br /> 39- 1 'o Gal <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUA COUNTY ORDINANCES, STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING,: .1 CERTIFY THAT IN THE PERFORMANCE Or THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS i-SSUEU, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE�. I,- TITLE vat <br /> El APPROVED PPROVED WITH CONDITION(S) El DISAPPROVED <br /> , (SE CONDITIONS BELOVJAND/Oj ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FRO418 JP;/CAOMUST BE SUBMM6 2T LEHD FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDI I S: <br /> FH 23 046 (Re-vised 10130/12) 3 <br />