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SAN 10% c UIN COUNTY PUBLIC HEALTH ; :VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ClkREMOVAL J)PIOCZ_ ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CME(�22�3�33 PROJECT CONTACT `��-\ `t [ i\CEJ` PHONE# C I �Y4Lf <br /> FACILITY NA <br /> ADDRESS <br /> CROSS STREET 1 - � <br /> PHONE# <br /> OWNER OPERATOR Zn <br /> c <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME t '��; L N' l 1� C_� PHONE _ - J <br /> CONTRACTOR ADDRESS p ;} V Z _ -_ L � CA LIC#7� 76 1 CLASS <br /> INSURER_ - WORKER COMP# 1 <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME �rlj COUNTY PHONE 50 1 ` Cfl <br /> SAMPLING FIRM \ � _ PHONE It V-N-QLO <br /> J- TANK INFORMATION <br /> TANK 10# K SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39— I 1 VI <br /> 39— <br /> 39— <br /> 39 <br /> 39— N <br /> 39—"ll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LA SOF CALIFORNIA." <br /> APPLICANTS SIGNATOR TITLE ���DATE- <br /> OAPPROVED <br /> APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> �L DATE <br /> PLAN REVIEWER'S NAME v' Li, <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK- <br /> CONDITIONS° <br /> jr <br /> 1D <br /> tn_�L�1� '�n <br /> r <br /> EH 23 046(REVISED 10/19/98) age 3 <br />