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Jul 31 02 07: 12p K*4►,'• Curtis Construction 2m+-234-2411 p. 3 <br /> SAN JOAQUIN COUNTY IIHM IC. HEALTH SERVI( +,'ti <br /> ENVIRONMENTAI HFAI_TH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> 111' PFHMII 1 01?P 144MANI N I/I'EMI'gRARY 1:1 11St❑Hb LIN AHANIX 110,11 NI IN PLACE Of UNDERGROUND NAZARI)UUS SUBS ANCE$ <br /> I IkAL-, I ANK(3I I XPIRI S 90 DAYS FROM THE APPROVAI OAT( 111)NOT W RI1 E IID ANY SHAUFD AHFAti IIJDIC ATE PERMIT T'e. <br /> V <br /> {REMOVAL 0 TEMPORARY CLOSURE n- CLOSURE IN PLACE <br /> L FACILITY INFORMATION <br /> EPA SITE N P OJECT CONTACT <br /> FACILITY NAME PHDNE# <br /> V <br /> ADDRESS PHONE* <br /> CHOSSSTREET l <br /> OWNER OPERATOR 92 <br /> PHONE# / <br /> L <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 1 / ONS <br /> CONTRACTOR ADDRESS 3 /O OPHONE#_2 <br /> b. INSURER g/a CA LIC# g 9 00 CLASS / <br /> FIREDISTRICT WORKER COMP# <br /> LABORATORY NAMEPERMIT* <br /> SAMPLING FIRM <br /> L U A COUNTY AG'E-O NE# <br /> Q �. / <br /> PHONE # <br /> L <br /> TANK ID TANK SIZE TANK INFORMATION <br /> p TANK CONTENTS PRESENT H PAST <br /> I 39- � S O u.✓/Lp DATE INSTALLED <br /> 39- <br /> pip 39- D <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNT'ORDINANCES,STATE LAWS, <br /> j REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SFRV FEDERAL LAWS,AND RULES AND <br /> CERTIFY THAT IN THE PERFORMANC-- ICES- OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING. -I <br /> TO E OLLO ING-I TRT WORKERS C0.:IPENSAOgNFLAWSIOC CALIFORNIAH.THIS !I IS CONTRA^CD.I SHALL NOT TOR-S HIRING OR SUBCONTRACTING SIGNATURE CERTOY ANY PERSON IN SUCH A IFIS <br /> IES <br /> THE FOLLOWING: 't GCRTIFY THgT IN THE PERIURMANCE OF THE WORK FOR WHICH TNIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SLIBJECT TO <br /> WOfMER'S COMPENSATION LAWS OF AUF• NIA,- <br /> ■. APPLICANT'S SIGNATURE LE—_�L Ate! 1710 DATE <br /> �. ❑ APPROVED PROVED WITH CONDITION S <br /> O DISAPPROVED <br /> II y IS-E CONDITIONS B W ANO/OR ON ATTgCHIAENI) <br /> PLAN REVIEWER'S NAME <br /> _J1 I) /� <br /> V DATE /S� <br /> ANY DEVIATIONS FROM.THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CN ITIONS: <br /> s <br /> I <br /> j <br /> CH <br /> _�Gi;(RE ViSEiJ 0Ei1liv5) <br /> f'dJV;.vi <br /> V� <br /> L <br />