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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DAT . DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # C' oor - ,;Z,�5 PROJECT CONTACT & TELEPHONE -3 <br />F FACILITY NAME 3jt}y �5 ryI ( �qIQ k� PHONE <br />A 33ob WEST LAAf 5'ZockzoiQ CA q62-04C ADDRESS <br />I <br />L CROSS STREET A•LPI NE <br />I PHONE # <br />Y OWNER/OPERATOR TAy J m� me I LPAZH 2-09 - 466--116132 <br />�J $ <br />C CONTRACTOR NAME WAL"TO� � <br />EW6jjl)RlfQ# N6, PHONE # Cf1b_3-73- 68 <br />0 CA L I C# l �- 2 3 8 A B P(A-& <br />N CONTRACTOR ADDRESS P p Bax 1 pZ$" �G, 95�j`� 1 6 CLASS <br />T <br />R INSURER 'FaEryfol)T Cor4QE1J5AT DIn WORK.COMP.# WN 6 51'7 3 6oZ I t `I <br />APERMIT # <br />C FIRE DISTRICT SZflGIKT-,y J FlD6?-c- <br />TGAi ir-- LA*IXO- j COUNTY <br />0 LABORATORY NAME CLS IZ'J�J 569.11 5gC2�r/46iiZp PHONE # q ((7- (0,318-7301 <br />R3 CLAS Tod PHONE <br />��- °I I6-X56-644 <br />SAMPLING FIRM 'N S$g} # <br />I I I I I I I I I I I I f l 1111111111111111 <br />TANK ID # Q TANK SIZE CHEMICALS STORED CURRENTLY/PRE IOUSLY DATE ��INSTALLED <br />39- - I 1 s, oC1U M10. U G ►5 <br />ALL ota <br />T 39- - 2 10 000 R ~ n M <br />~ 64 ~ i <br />N 39- <br />K 39- <br />39- <br />39- <br />llil!llllllillliitllll11111111 1111111111111111111111 IIIlflli lllllllllilllliilltlllllllllllllllllll I1111111111111111l1lI <br />P <br />L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) / <br />NDATE ! - <br />PLAN REVIEWER'S NAME <br />111111111111111111111111111 1111111111111111111111111111 II 1111111111111111111111111111111111111111111ilfiillllllflllllill <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT INTHE PERFO ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF N " <br />APPLICANT'S SIGNATURE( TITLE ^ DATE <br />CONDITION(S): <br />EH 23 046 (Revised 7/10/96) Page 3 <br />