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SAI�JOAQUIN COUNTY PUBLIC HEAASERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS 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 /> [(REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#7?'r 7 2. 1 PROJECT CONTACT -71 rn GO r 11 E-1 I PHONE# Zcq_cjb -20!y <br /> FACILITY NAME p0.G( L 1'n I l I - MO-r+- 't- &CLS JPHONE# 1.0 q-47 3- 1171 <br /> ADDRESS Lf 5 11 Pa G i f, G &V e tt 20 7 <br /> CROSS STREET o e m ar li e, I. v1 e. <br /> OWNER OPERATOR (ao.. O - PHONE# 2041-473-'111 <br /> pir+ W a.++- L .Aa oInner 20 -151-120-7 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEoL 1!)ef✓ri n PHONE# 'LOq Ip -Z4 <br /> CONTRACTOR ADDRESS r A le or/1 e- lAqV • CA LIC# 12- CLASS A Z <br /> INSURER LL WORKER COMP-_ 113- Z. ' <br /> FIRE DISTRICT CNu 8 +DL PERMIT# -I"- 4plihm, <br /> LABORATORY NAME (.Al C-h itAW foramen COUNTY h A i R PHONE# <br /> SAMPLING FIRMnv I r0 n men PHONE # — 0 <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- a 12 000 Itil1e0-cam 0461 rLe. /99 <br /> i 39- - 6,000 Mild toLde- <br /> 1139- r2 1 1000 l ti <br /> 39- 2 bifk <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING -1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 LAWWAF CALIFORNIA' <br /> APPLICANT'S SIGNATURE TITLE DATE ✓" '� <br /> I <br /> ❑APPROVED 01-APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 'A' <br /> `_4_- DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO D FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> ON ITION <br /> G� 1 i �,%_ <br /> EH 23 046(REVISED 08/13199) Page 3 <br />