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S JOAQUIN COUNTY PUBLIC HEAL- SERVICES <br /> '*we' ENVIRONMENTAL HEALTH DI\*ON <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> P(REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACTPHONE# <br /> FACILITY NAME PHONE# <br /> ADDRESS <br /> CROSS STREET <br /> OWNEROPERATOR PHONE# / <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME I /YS O PHONE# <br /> CONTRACTOR ADDRESS A R CLIC# ie CLASS I <br /> I INSURER WORKER _OMA <br /> FIRE DISTRICT PERMIT# <br /> LABORATORYNAME COUNTY � e,+-O NE# I4 J <br /> q SAMPLING FIRM I j iV 4 A IJ I WfigrA 1 1 PHONE # <br /> i TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- S o ufV1 A )[lel <br /> 39- o O L ed u <br /> 39- joS U <br /> 39- <br /> 39- <br /> 39- <br /> i <br /> I <br /> -i 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 7 <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 SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF AUFORJIA' <br /> APPLICANT'S SIGNATURE LE D/�IjG� //Kl�.� DATE /D <br /> ❑ APPROVED IDAPPROVEDC NDITION(S) ClDISAPPROVED <br /> (SEE CO ITIONS BE W AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ' ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMRTE TO EHD FOR APPROVAL PRIOR TO COMMENCIN WORK. <br /> DITIONS: <br /> EH 23 046(REVISED 08/13/99) Paye 3 <br />