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Jan- 13-99 02 : 39P pile construction <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE C%F!ABANDONMENT IN PLACE OF UNOERGROU NO HAZARDOUS SUSSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INOICATE PERMIT TYPE: <br /> REMOVAL Cl TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> c`PA SITE+ 1 PROJECT CONTACT k I PHCNEk - J <br /> FACILITY NAME �{ ;HONE M <br /> ADDRESS ifir LvAnipk <br /> CROSS STREET <br /> OwNERCPERATOR LAST OperatoT Exxon Comany USAaHONE+ � <br /> CONTRACTOR INFORMATION <br /> CONTRAC 4SMUCTION PHONE V <br /> CONTRACTOR AOORESS P,0. bDX CA LIC CUSS A <br /> INSURER I WORKER COMA+ 1 <br /> PIKE DISTRICT I PERMIT+ g-/2 <br /> LABORATORY NAME a a CDU dHONE+ <br /> S,ALIPuNO FIRM PHON <br /> TANK INFORMATION <br /> TANK 100 TANK SRI TANK CONTENTS(PRESENT 6 PAST! ! DATEINSTALL2D <br /> TMT- <br /> 39- 121104 10,000 gallon Regular Unleaded 'W1.13ry <br /> 39- 1?11 nI in.nno ml Icn Regular Linleaded Japuary 1989 <br /> 39- Premium, Lhleaded jEnuary 1989 <br /> ! 39- <br /> 39 <br /> 39- I <br /> APPLICANT MU57 PERFORM ALL WORK IN ACCOROANCE WITH SAN JOAQUIN COUNTY ORDINANCE5. STATE LAWS, F;OERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN �OAOVIN COUNT' PUBLIC HEALTH SEAVICES. OWNER OR LICENSED AOENTS SIGk4TURE CERTIFIES THE FOLLOWING: 'I <br /> CERnFY THAT IN T11E PERFORMANCE OF TME WORK FOR WHICH THIS PERMIT S ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUGM A MANNER A$ <br /> TO BECOME SUBJECT'0 WORKER'S COMPS J}i pQN LAWS OF CAU9CRNI.ti CONTRACTOR'S nIRING CR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLCVNNG. 'I CERTIFY TN' <br /> !1 71� <br /> E OFTMEWORK FORwHK:M MB PERMR S ISSUED. SJ•LALL EMPLOY PERSONS SUBJECT TC <br /> ,YORKER'S COMPENSATION l <br /> APPLICANTS SIGNATURE ^ TITLE '7f_:CWuy/L�Iv1—111 _,0r7 DATE ] <br /> CI APPROVED Q APPROVED WITH CONDITION(S) Q DISAPPROVED <br /> {SEE CONDITIONS BELOW AWYOA ON ATTACWF NT) <br /> PLAN REVIEWER'S NAME GATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> HH 21 W tRFJJSFC i 0119/96) <br /> ELiG'd EG2D-299-G�1C-7Fl7H-'�u'o-nx�� Iczl ia•rr cc �. ,�.� <br />