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SAN .orUIN COUNTY PUBLIC HEALTF RVICES <br /> NVIRONMENTAL HEALTH DIVI. <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> IT ORUS SUBSTANCE <br /> THIS PERM <br /> SPLAE OF <br /> HRD <br /> RARY <br /> SURE <br /> NMENT <br /> UNDERGR <br /> UND <br /> TORAGE TANK(S)FOR <br /> EXPIRES 90 DAYS OFROM THEOAPPROVAL DATE.ODO NOTIWRITE CN AANY SHADED OAREAS. INDICATE PERMIT TYPES <br /> EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT IL y PHONE.# <br /> FACILITY NAME PHONE, ��7 <br /> ADDRESS <br /> CRO S STREET D <br /> OWNERPERATOR /� /� CC � " �� PHONE <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 04 �^ PHONE-, 16?�Z5D�3 <br /> CONTRACTOR ADDRESS tt- 4ic� �7 ZI CA LIC n v� 1 CLASS <br /> INSURER CL;r l G� S^ WORKER COMP# <br /> FIRE DISTRICT PERMIT# Un <br /> LABORATORY NAME �iCC'[ ✓r COUNTY �� PHONE# <br /> SAMPLING FIRM J,- zj PHONE r � " <br /> TANK INFORMATION <br /> TANK ID TANK SIZE Q <br /> CONTENTS PRESENT& PAST) DATE INSTALLED <br /> —t— zL I <br /> 39- © k 6O1 ��gD 0 <br /> 39- O t ODC 2- <br /> 39- d b 0 3 6111�11u42SL <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S 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 SUBCCNTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANC F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALI R <br /> APPLICANTS SIGNATUR <br /> TITLE � DATE !4 `( t <br /> ❑ APPROVED 7APPROVED WITH CONDITION(S) El DISAPPROVED <br /> (SEE CO DITIONS BELOW AND/OR ON ATTACHMENT) <br /> c <br /> PLAN REVIEWER'S NAME DATE I <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTE O EHD FOR APPROVAL PRIOR TO COMMENCING ORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 08113/99) Page 3 <br />