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SA.JQUJN COUNTY PUBLIC HEALTH aCES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PEPUNUT <br /> THE PERMIT FOR PERMANENT/TEMPCRARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE ?E.2MIT TYPE 3ELOW: <br /> /REMOVAL REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> 14?f 372 <br /> EPA SITE PROJECT CONTACT & TELEPHONE - <br /> Ci�l. o0o n45- 4ZD I MIKE l.£L� � Gu4C.Tas� tr7+/Gl�7Z�tiIl� <br /> FACILIT7 NAME GtUIr SroP * 12) I PHONE <br /> I I ADoa£ss l l (o W. U t AVE MAWT&Z/� CA- <br /> 7C <br /> � <br /> L CROSS STREET (J^/I OA/ � <br /> I <br /> 7 I OWNER/OPERATOR PHONE " <br /> Y 62Ut K 5�P Maw-C�TS� INc, �5/0) 65-7-S S� <br /> C I CONTRACTOR NAME LAAL� J� <br /> &W60 �/L 6-/ 11UC. PHONE ql�o 73 ^f 168 <br /> 0 <br /> N CONTRACTOR ADDRESS 4S'Ltl CA LIC CLASS <br /> T P,O• !02 S ►J•ALO 61 238 i 8 yfit-Z- <br /> R INSURER r-aeM ,rr C orcp6X6A7!art 1 AJSU,�,�•ZF � WORK.Cc:MP.�W�6� <br /> A -?L3 bot <br /> T I FIRE DISTRICT MAWrRA pp� (,a'p't UVJ N14WLE 2A'�•2Y1 8061 PERMIT <br /> RLABORATORY NAME C L5 LAS 12 3 I COUNTY SACC M6�p I PHONE <br /> I SAMPLING FIRM C0MPLIt"C.F C-LOSUF-6-1 &AV2 f AtUL.r-u i ?NONE `�$t_) 42-(0 ITS- <br /> TANK <br /> sTANK ID d TANK SIZE CHEMICALS STORED C-''RRE4TLY/PREVICUSLY DATE UST INSTALLED <br /> 39- - t 1 O 000 �+YtL • l U�Lt?9D /.�4 Scc.� /9 8¢ <br /> T 39- I t^Z- <br /> A 39- - o� � s�-C c I •� n t r, <br /> N 39- <br /> K 39- l <br /> 39- <br /> 39- f <br /> IP <br /> lllII1111lIlllllllllif! 11111 Illll iillililill1111111111111111111111!!11 lltlilltllll lllEl!l1111l11�ll111111III HI 1111111 <br /> L APPROVED APPROVED WITH CONOITICN(S) DISAPPROVED <br /> A (S' CONDITIONS 3ELCW ANO/CR ON ATTACHMENT) <br /> � N <br /> ?LAN REVIEWER'S NAM <br /> DATE 9 <br /> i 111111!IIlIlIllllllltllll}lIlliillllI11111I11111l111111111tittlllllllll1111111111Il11i11111111[Ilffllllllllillllilllllil11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIHANC=S, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAGUIN COUNTY PUBLIC HEAL7H SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO 3ECOME <br /> SUBJECT TO WORKER'S CCMPENSATION LAWS OF CALIFORNIA." CCNTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES .THE FOLLOWING.; <br /> "I CERTIFY THAT IN THE PERF C OF THE WORK R WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL I FC N A." ,,��°° i 2 v✓, q. r <br /> /fnA u1• E <br /> APPLICANT'S S I GNATUR v�L U T I TLE l�4 D0rr. lyi/✓C7�. DATE <br /> WXTLtai/ OV4I/4192IIWf7 <br /> CONDITIONS): <br /> Es 13 046 (Revised 9/11/96) Page 3 <br />