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SAN JCSUIN COUNTY PUBLIC HEALTH &VICES <br />ENVIRONMENTAL HEALTH DIVISICNI <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />IsTHIS 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 />• <br />is <br />C[`REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />APPLICANT <br />FACILITY INFORMATION <br />39 <br />EPA SITE #4, <br />PROJECT CONTACT / JI p c y� t _ C /v' <br />PHONE# �' �". �� c F <br />FACILITY NAME <br />; .. ,� i <br />PHONE # ,. F _ > is c ! y <br />ADDRESS <br />WORKER COMP# <br />- � <br />CROSS STREET - <br />Nc H ° 39 `y ]PERMIT # <br />7 -)C,1 -1V7- AA%S COUNTY',/.► %t,jqjiI&Ar. PHONE#(%/� <br />OWNER OPERATOR <br />L'.,y <br />PHONE # <br />TANK INFORMATION <br />APPLICANT <br />CONTRACTOR INFORMATION <br />39 <br />y <br />CONTRACTOR NAME= F <br />PHONE # 9,f,4K <br />4jj'-d,01 <br />CONTRACTOR ADDRESS <br />:- / i - , l� CA LIC #C/ 30 Z 7 <br />CLASS <br />INSURER <br />WORKER COMP# <br />- � <br />FIRE DISTRICT 4 <br />LABORATORYNAME S/- 1L'&-�/,'JV <br />Nc H ° 39 `y ]PERMIT # <br />7 -)C,1 -1V7- AA%S COUNTY',/.► %t,jqjiI&Ar. PHONE#(%/� <br />SAMPLING FIRM <br />7-/y PHONE # <br />TANK INFORMATION <br />APPLICANT <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39 <br />CC�«i <br />39- <br />9-39- <br />39— <br />39- <br />.39— <br />F3 —9— <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 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 SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE[ - !'rt 1,�. -r/iA 6 G7- TITLE <br />❑ APPROVED JK APPROVED WITH CO�PZNDIT�ION(S ❑ DISAPPROVED <br />(SEE CONDITIONS BELO AND/O ATTACHMENT <br />PLAN REVIEWER'S NAM DATE <br />ANY DEVIATIONS FROM THIS APPLICAT N MUST UBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />., _ _ „ ten— _ e _ A _ _ — COJVD_ITIONS: <br />EH 23 046 (REVISED 08/13/99) rage 6 <br />