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SANIN COUNTY PUBLIC HEALTH SE ` )CES <br /> .`JUAVIRONMENTAL HEALTH DIVISIONIIW <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THS STIORAGE TANKIS)EXPIRET FOR NS 90 DAYS FROMTCLOSURE Oft ABANDONMENT THE APPROVAL DATE. DO NOTIN PLACE OF WRITE MI ANY UNDERGROUND <br /> AREAS. INDICATE PERMIT TYPE. <br /> p REMOVAL p TEMPORARY CLOSURE CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE f 172 PROJECT CONTACT l, i PHONES <br /> FACILITY NAME PHONE K <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR PHONE <br /> CONTRACTOR INFORMATION <br /> E <br /> CONTRACTORPHONM <br /> CONTRACTORAODRESS <br /> CA UC S 7i CLASS - <br /> INSURER WORKER COMPS <br /> FIRE DISTRICT PERMIT f - <br /> 000NTY PHONE <br /> LABORATORY NAME PHONE <br /> OAMPLINO EIRM <br /> TANK INFORMATION <br /> TANK IDR TANK SIZE <br /> TANK CONTENTS(PRESENT 6 PAST) DATE INSTALLED <br /> �S <br /> 39- <br /> 39- <br /> 39- <br /> FEDERAL LAWS. <br /> O RULES <br /> APPLICANT MUST REGULATIONS OF SAN OJOAOUIN COUNTY PUUIC HEALTH SERVICES OWNER OR LICENSED AGENTS 5 IG RE CERTIFIES TNEµOLLOWING:As <br /> C� <br /> CE BECOT�T IN THE ME SUBJECT TOPERFORMANCE <br /> WORILERN SEOF THE WORK FORCOMPENSATION LAMS OFWHICC AUFORNU THIS T CONTRACTORS HIRING NOT OR SUBCONTRAOnNG LOY My PERSON ISIC'NATURE GEHET�FTE3 <br /> TCB BECOME <br /> FOLLOSUB 'I CERTIFY TW RKETTi^ R1 THE P ORW�NCE OF WORK FOR WHICH TH16 PERMIT M ISSUED,I SHALL VAPLOV PGRSONS SUSJ6CT TO <br /> WORKER'S COMPENSATION LAWS OF LA <br /> // ../j / TTLE DA <br /> APPLICANTS SIGNATURE <br /> p DISAPPROVED <br /> ❑ APPROVED ❑ APPROVED mmoomsBELOWNANMOINATSucwENT <br /> DATE <br /> PLAN REVIEWER'S NAME <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST CONDITIONSEHD FOR APPROVAL PRIOR TO COMMENCING WORK' <br /> CN 2J O46(REVISED 10MV96) Page 3 <br />