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SANC�"'N COUNTY PUBLIC HEALTH S�VICFS <br /> EN..AONMENTAL HEALTH DIVISIO <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT(TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF LINDERGROUND HAZARDOU3 SU53TANCFS <br /> STORT I&� <br /> (S)EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE W ANY SIVIDED' / <br /> AREAS. INDICATE PERMIT TYPE- <br /> REMOVAL ❑ TEMPORARY CLOSURE /CLOSURE IN PLACE <br /> FACILITY INFORMATION //uu ' <br /> )' PROJECT CONTACT i PHONES <br /> EPA SITE S LLQ PHONE# <br /> FACILITY NAME <br /> ADDRESS <br /> CROSS STREET PHONE S <br /> OWNER OPERATOR <br /> CONTRACTOR INFORMATION <br /> PHONE+ T—/�6. <br /> CONTRACTOR NAME ✓(/ U LIC# Z CUSS - <br /> CONTRACTOR ADORES' yypRKER COMP# <br /> INSURER <br /> PERMIT# <br /> FIRE DISTRICT) <br /> COUNTY PHONE# 4G - <br /> LA80RATORYNAME PHONE <br /> 3AMPUNO FIRM l ' <br /> TANK INFORMATION PATE INSTALLED <br /> TANK ID R TANK SIZE TANK CONTENTS(PRESENT L PAST) <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> SAN <br /> 9- <br /> 39- � l <br /> 39- <br /> 39- <br /> 39- <br /> APPUUNT MUST PERFORM ALL WORK M ACCORDANCE WR11 SAN JUOUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL 1AWWS-AND RULES AND <br /> NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> REGULATIONS T SAN lRM ALLUMN WIN PUBLIC HEALTH SEINCES. OWNER DR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR~ICH TMS PERMIT IS ISSUED.I SNALL <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS DF FORMA' CONTRACTORS NVUWW OR SUBCONTRACTINGPLOY PQRSONRE RJSLI TE <br /> THE FOLLOWING. '1 CERTIFY THAT M THE P ORMNNCE OF�N FOR NMIGH THI6 PERAfT 16 166VE0. GHALL EMPLOY PCRSONS SUOJL,C/T TO <br /> WORKER'S COMPENSATION LAWS OF <br /> - / TITLE <br /> APPLICANTS SIGNATURE <br /> ❑ APPROVED APPROVED VNTH CONDITIONS) <br /> ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDAR ON ATTAC/PENT) <br /> DATE <br /> PLAN REVIEWER'S NAME - - <br /> ANY DEVIATIONS FROM THIS APP TION MUST CONDITIONS:END APPROVAL PRIOR TO COMMENCING y/ORK. <br /> 'T- <br /> I 1 <br /> � - <br /> EH 21 OAO(REV W ED 10/t 9NS) <br /> Pa9S <br />