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SAN, ' UIN COUNTY PUBLIC HEALT. VICES <br /> ENVIRONMENTAL HEALTH DIVIS OONN� <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> I THIS PERMIT FOR PERMANENTffEMPORARY 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. INDICA—,E PERMIT TYPE: <br /> i� <br /> 93'REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> II , <br /> } 1 FACILITY INFORMATION <br /> EPA SITE*4CWC Q r-1 2 /p C I PROJECT CONTACT `f I PHONE# <br /> FACILITY NAME' PHONE# <br /> ADDRESS Ue N LrwIr <br /> CROSS STREETz1"? crG - <br /> OWNER OPERATOR t� PHONE# <br /> .E <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# <br /> .. CONTRACTOR ADDRESS 047 1`CA LIC,',# I CLASSJ/,q2" <br /> k INSURER WORKER COMP# ((} D f LJ <br /> FIRE DISTRICT I PERMIT <br /> LA130RATORY NAME S COUNTY I? PHONE# <br /> SAMPLING FIRMcJ PHONE jpq-,D38 q2 g4 A2109 Ira I -2thwc- <br /> TANK INFORMATION I� <br /> TANK ID* I TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39— 160 i <br /> 39- <br /> 39— <br /> ,I 39 <br /> 39— f <br /> =a <br /> 39— it <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'AGENTS 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 SU8CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT 1N THE PERFORMANCE OF i HE WORK FOR WHICH THIS PERMIT IS ISSUED ,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CA41FORNIA.- E <br /> APPLICANTS SIGNATURE T _ v >> v < �'�v TITLE— -l.j'V _..._.. DATE <br />! ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEI=CONDITIONS BELOW ANDIOR ON'ATTACHMENT) <br /> PLAN REVIEWER'S NAME I DATE451� f <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE VBMIlTI;D TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> - CONDITIONS: _ k <br /> .a <br /> 4z g:244a <br /> I <br /> EH 23 DabREVISED loll ? Page 3 <br /> d� ,* <br />