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------------ <br /> A <br /> SAN JOAQU 1; -'OUNTY PUBLIC HEALTH SERV/ <br /> ENVIPONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNE i-::"RGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENtaEMPORARY OR ABANDONMENT IN PLACE OF UNDERGIRCUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK ) EXP{RES 90 DAYS FROM THE AF-:DROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE: <br /> ;RZE:MOVAL F] TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> Fi".CILITY INFORMATION <br /> EPA SITEROJECT CC,,:TACT <br /> PROJECT PHCNE# foq-d�LLI ZZ3 <br /> FACILITY NAME LPHONE# <br /> ADDRESS !Z-7-oro <br /> CROSS STREET <br /> �PERA�TT®R PHONE#Z e'q-zii <br /> CojL "-F <br /> RACTOR INFORMATION <br /> CONTRACTOR NAME SV ' <br /> -pac, NE# <br /> PHO fog -4,cy-9-1 <br /> CONTRACTOR:ADDRESS CA LIC#,30 eos- CLASSC6 0 <br /> INSURE 1AX4 <br /> WORKER COMnao <br /> FIRE DISTRICT PERMIT* <br /> LABORATORY NAME I COUNTY 6& PHONE9.176-92Z <br /> SAMPLING FIRM 1 <br /> jpjr44 PHONE - Ze�f -J4 6,7 G <br /> TANK INFORMATION <br /> TANK 10# 1r TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 3 9- <br /> 39- <br /> Ll 1-k Lv�xnc-A7 <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCQRDANCt ATH SAN JOAQUIN COUNTY ORMNANCES,STATE LAWS. FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN XAQUIN COUNTY PUBLIC HFA. . SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY 7HAT IN THE PERFORMANCE OF THE WORK F::.- V'IHICH --HIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> 70 BECOME SUBJECT TO WORKER-Is COMPENSATION '-.•.'!S OF CALiFORNLA.* CONTRACTOR'S HIRING OR SU3CCNTRAC-llNG SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFYT HAT'=IINTIHE PER OR� W THE WORK FOR WHICH THIS PERMrr IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION <br /> APPLICANT'S SIGNATURE <br /> TITLE 10d DATE <br /> OAPPROVED '0 APPr,.(-')VED WITH CONDITION(S) 13 DISAPPROVED <br /> 'SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM TEAS APPLICATION 1",:,'j5T BF SUBMITTED TO EXD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> j 23 <br /> T/T <br /> TI I I E—'A SE—Di C I 1 9 8) <br />