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r <br /> t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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#?'r PROJECT CONTACT ?I M Cor n e-11 PHONE# Zo q-/b -zo/y <br /> FACILITY NAME a0.C1 '4 m i n I - Mol* cLs iPHONE# <br /> ADDRESS i>4 L 1 Ci V e - <br /> CROSS STREET o e m CLI <br /> OWNER OPERATOR IP Q a 10 etfal O PHONE# Zo9'-47 3-117 <br /> At+ w a+t- L. LAA o Inner 20 -9sl-120-7 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME VOL 14 eer, n PHONE# 209 (p -20 <br /> CONTRACTOR ADDRESS ^ r/1 CA LIC# I Z CLASS I JoA7— <br /> INSURER <br /> WORKER COMP# -I13' Z <br /> FIRE DISTRICT O +D C. PERMIT# W <br /> LABORATORY NAME I C-k tAVi t n men COUNTY Yl tI i fi PHONE# <br /> SAMPLING FIRM nv /O n M e tt PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- (2 00[7 (,>(nleadect' a.sol;nf_ III <br /> z 39- 6,000 /i1r cL d4E, �r <br /> 39- D i <br /> 139- <br /> -3-- <br /> _ 39- <br /> APPLICANT <br /> 9-3 - <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 FOLLOW tNG: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAW CALIFORNIA." <br /> I Nhh"f APPLICANT'S SIGNATURE TITLE DATE ✓" '0 <br /> I <br /> ❑ APPROVED DAPPROVED WITH CONDITION(S) ❑ DISAPPR VED <br /> (SE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME A / �l `- - DATE J� <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCIWG W RK <br /> CONDI 10 1 . ' \ <br /> - 4 � <br /> EH 23 046(REVISED 08113199) Page 3 <br />