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IRONMENTAL HEALTH DEPART" NT <br /> APPLICATION Fqff UNDERGROUND STORAGE TACLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# d Dp¢S¢ PROJECT CONTACT , -c c r��r�' PHONE# 9i6, G P¢,46 jZ s' <br /> FACILITY NAME v;2�' 1 etep NCLG PHONE# ZD9. <br /> ADDRESS sz.SY 4fI- ,--i 2,- S— tTfl,�/ L'•� <br /> CROSS STREET [ YKau>N o-A-= ' <br /> OWNER OPERATOR PHONE#Zo9% 7 f p z¢ <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 4747 N , PHONE# <br /> CONTRACTOR ADDRESS O 0S, ,tr CA PS-7j CA LIC# ^o ¢$' CLASS,.dC,g/ D 19 <br /> INSURER 7I� P�,vr Yid -',,, uti L�✓�No WORKER COMP# s-oZ -oZ o <br /> FIRE DISTRICT 7ri{��tru �e`c ,��,- PERMIT# ,w, <br /> LABORATORY NAME=,- COUNTY 4:-4, 664 PHONE# cI Z S, Q p¢% i y i9 <br /> SAMPLING FI -d Al le,A Cry PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENTS PAST) DATE INSTALLED <br /> 39- 4!¢l -Ae / S o ,�� te,a a -n sdz. / 9 S <br /> 39- ,�60 .rP, i S o o /�iCE�r,.cM v�ooa� a�..✓c: / 9 s <br /> +14!:- <br /> 39-/,y6/4¢-zi0 So l Jisz-�'-vim / 4 P �z <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,1 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 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 CA FORIA." <br /> APPLICANT'S SIGNATURr� "em� C <br /> ITLE //Z 67�C7' /7.(a/.d6g� DATEb 7 d <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 10/16/03) Page 3 <br /> 1. (a) Is there a EHD contractor's and subcontractor's questionnaire on file or enclosed? YES[] NO <br />