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PA <br /> (J <br /> ENVIRONMENTAL HEALTH DIVISION 11MMM f <br /> MAR 5 f�92 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT SAN JO1992 <br /> O <br /> ,I EN Rnsp 1C HEALTHOUNTY <br /> APPLICATION FOR PER N.ANENT/TEMPORART CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARD OLIS'` E&-4gqj8AR�YUM I TY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYP EPNON <br /> +� REMOVAL TEMPORARY 'CLOSURE CLOSURE IN PLACE <br /> tAAFzF, MDO RE Fo <br /> EPA517:E R [�A L„`. �Z S�S PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME 6riltp4 -jEI2.V1C STATION 13-7 PHONE (ZO14 2fvg0 <br /> A I' <br /> C ADDRESS I(PCCj {jDIJTi-t �- pdR,Ak7� !�V 11 I�1V , 5Z-4GKTdN C • <br /> L CROSS STREET �jEG..OI�LC7 �jTR��G� <br /> 1 <br /> T OwHERIDP:RATOR �xKaN GOMPAN� i LJ,S . PHONE <br /> Y `x710) 7A(o 97 Z(o <br /> C CONTRACTOR NAME CYDL.D�►� WE`�T �Vll.DI=FSS PHONE M 6415} Lo34� 1gR8 <br /> OL 10100 m114N&sOTA AV rz <br /> N CONTRACTOR ADDRESS 4 k5get C yvpav C..A �4P-) CA LIC 432{O 3 CLASS Ar <br /> T STATE FUND - v-tow-K-.EK'S coMp <br /> R INSURER WORK.COMP. {4'a(p ' D <br /> A <br /> C FIRS DISTRICT GGtTy aF PERMIT R <br /> T <br /> 0 LABORATORY NAME PA[.E L.APl�j NavATO L.A PHONE C41S) 883 Co10-D- <br /> R i <br /> SAMPLING FIRM - ASC IS IMNVIFLOiN ME:,NTp.L. IML. t pbevIl.Le Ch. PHONE : �,�{{p) "�gj'L-' 'z,{{Q <br /> III I I I I I l I I f I I!I!I l IjI I II I I I I II <br /> TANK 1D K TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39-_ _I 2� 0-1 to , c>O D AG yoke UNLel Qeb fxAeU M14t� W <br /> T 39- I LYJ 2 'D-z' 104 0 VNK <br /> A 34 -- �r�a3 - O DGD P I� AS V <br /> N 39- <br /> K 39- 'I <br /> 39- <br /> 39- <br /> P III II III II III II II IiI lI lIl Il III I IIIA II III I[III[Jill II II III II II II III II III II IIIIIII III II II1II II IlI Il III I IIf II III II II VIII III <br /> L APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED <br /> AA( AT7 HMENT WITH C DITIONS) <br /> N PLAN REVIEWERS NAME!I DATE <br /> IIIIIIIIIIIIIIIIIIIIVIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIiIIIIlIIIII 1IlIIIIIIIIIIIIIIIIIIIIIII(IIIIIIIIIIIIIIIIIIItIIIIIIIIII <br /> APPLICANT MUST PERFORM1iALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBUIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A-MANNER AS TO BECOME � <br /> SUBJECT 70 WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SU8JECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> r <br /> i, <br /> APPLICANT'S SIGNATURE: TITLE F� TE Z -pZ i <br /> I <br /> EH 23 046 (Rev 2/8/91) f,'l Page 3 j <br /> �I f <br />