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RECEIVED <br /> E'll 11 <br /> ENVIRONMENTAL HEALTH DEPART919 <br /> F6 2014 <br /> ONME <br /> SAN JOAQUIN COUNTY HMI <br /> e <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 IN ANY SHADED AREAS. INDICATE PERMIT TYPE: j <br /> REMOVAL ❑TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPASTTE# U PROJECT CONTACT PHONE# [Q 3 <br /> FACILITY NAME TOG JA i'llI PHONE#Co-U2 21 3e01 <br /> ADDRESS 1250 N. W i W!1 V S'1-OC,--Vj" " <br /> CROSS STREET GI <br /> OWNER OPERATOR j� PHONE# Z. 2 r..rdl <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME QI • SI PHONE# -1601 (MCO U32L <br /> CONTRACTOR ADDRESS I5 1 I CA LIC# CLASS <br /> INSURER WORKER COMP# q05 I( -6-101-5 <br /> FIREDISTRICT V/Vft it PERMIT# <br /> LABORA 26bm COUNTY I P ONE#OM61 -LnL4- LP <br /> SAMPLING FIRM 1 PHONE# HILI-11 <br /> S TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS RESENTAND PAS DATE INSTALLED <br /> 39- Oc3o5xjlbrl iO,000J'A_R_ <br /> 39- I lIT/t IYVL <br /> 39- 35 b 1 <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL`MIRK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOYANY 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 ISSUED, 1 SHALL <br /> EMPLOY PERSONS SUBJECT TO VOR 'SCOMPENSATI NNL.AWSOFCAUFORNL4.' / <br /> APPLICANTS SIGNATUR `" .5�./ TITLE ZI_41_1 if/I DATE_ <br /> ❑ APPROVED 0,APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> E CONDITIONS BELOW AND/OR ON AAH'ACRMEIITI / �T(tr <br /> PLAN REVIEWER'S NAMEy�C L. DATE <br /> ANY DEVIATIONS FRO THIS P LICATI MUST BE SUBM TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> • <br /> EH 23 046 (Revised 10/30/12) <br />