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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PER MANE NT/TEM PORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 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 JAl4-i/► L- wl►•Phoob-R-+T I PHONE# 200.sP,3. e)1.4.4- <br /> FACILITY NAME P>'P^V-CC j WG0$O PHONE# 201P. 460. 4P1 <br /> ADDRESS $ry Gam►. �✓' 3'30 <br /> CROSS STREET t N TE3t�GT�-T Fs <br /> OWNER OPERATOR PSP vV 640rr GO/-6rT' PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Grrrs i1'L-$fZ��Ylrtld 1 W G• PHONE# 92-5;. rJ5►. 7 099 <br /> CONTRACTOR ADDRESS CD'14.7 S►6FPo- GT. STC` J CA LIC# 224r7V 3 CLASSA b Glp S'7 <br /> INSURER TR'Aw%1C- %0.4► PWOP160" 44>- WORKER COMP# V'M)V 011110"1$io-4-41s I t= <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY PHONE# <br /> SAMPLING FIRM PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- I ' 12 coo "c.vLoa.iL / I 9-D84 <br /> 39- 1 X660 • A- <br /> 39- <br /> 39- p" 1xoov V%tz LuM Q/ IIVt.>4- <br /> 39- <br /> 39- <br /> 39- <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 AGENT'S 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." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIF AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'�, LA CALIFORNIA." <br /> APPLICANT'S SIGNATURETITLE PF�6C;t' M�+•+/�G�2 DATE Ia`t�7��ICp <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 07/22/10) 3 qOT <br />