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1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> i STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> )9(REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#eA B U 63 AS PROJECT CONTACT �� P F s�ri2 PHONE# 25 -67 —6707 <br /> FACILITY NAME -4-G -14 AAC <br /> M/44NTT---NWNC. TJr}'ryoAJ PHONE# -�2iS—l'IS <br /> ADDRESS 'Y'OS t 50Q7��./VkQ%JN tt'j 44 )US' H KW <br /> CROSS STREET O I' Hwy 20 <br /> OWNEROPERATOR P C,,-AS: PHONE#Z0C1' 35 -I YV3 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Al 4 1 PHONE# Z <br /> CONTRACTOR ADDRESS ES% L! S CA LIC# CLASS <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORYNAME COUNTY IPHONE# <br /> SAMPLINGFIRM PHONE # <br /> i <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> gg_ 7 p00 CGvL-kti Uw Dea G-45oLA4 e <br /> 39-2SL a 00 <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, OWNER OR LICENSED AGENT'S 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 '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAW OF CALLIF/ORRW.' XQ q <br /> APPLICANT'S SIGNATURE �/ `^� TITLE• DATE <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 08113199) Page 3 - <br />