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SAN JOAQUIN COUNTY <br /> E 'IRONMENTAL HEALTH DEPART _NT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT Marl(_ F rtc U PHONE# 7141 ?7'-(-2-t 7-4 <br /> FACILITY NAME Uli PIrsf- PHON E#,g 0j ql —r'3.,,{ <br /> ADDRESS <br /> ' CROSS STREET Q,2 <br /> OWNER OPERATOR P ifr 6e,-vUhd I C aPHONE# - <br /> ' CONTRACTOR INFORMATION <br /> CONTRACTOR NAME rld r iria?CnFq ter. r �� fn Gv�c, PHONE# -66 7_Z 3 op <br /> CONTRACTOR ADDRESS SOI PQ�KG H r Dr vG aH fu. Avi L CA LIC# ' � 26} CLASS <br /> ' INSURER s ��scif WORKERCOMP# cIIC�C�� fS� <br /> FIRE DISTRICT PERMIT# U -G <br /> LABORATORY NAME C-d r COUNTY CrPHONE# ff/6 —6 3 <br /> ' SAMPLING FIRM ?n ,,, PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- { tj n vrw,,r► <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 139- <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 ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY <br /> PERSONS SUBJECT TO WORKER S COMPENSATION LAWS OF CALIFORNIA" <br /> APPLICANT'S SIGNATURE TITLEV1 Ge— DATE 12 O <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> ' (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ' ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK <br /> CONDITIONS: <br /> EH 23 046{REVISED 3115102} Page 3 <br />