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11 <br />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 DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): v ®�j?A/� A r'/ �'- r�r°'-`i i/ Gr�j or' G•o �, , J <br />EH 23 046 (Revised 7/10/96) Page 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />F <br />A <br />FACILITY NAME � <br />PHONE # Zo y — .., r v 3 8� <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET <br />I <br />H.19 da <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />Av <br />'Z c/ --3 ms's -1G'3 <br />C <br />CONTRACTOR NAME yi <br />PHONE # ��� <br />0 <br />v <br />'• 3�e Z e 7 <br />N <br />CONTRACTOR ADDRESS <br />ekrwl <br />CA LIC #cJG'/ <br />CLASS <br />T <br />_ _ <br />_ ,% <br />R <br />A <br />INSURER <br />WORK.COMP.# <br />C <br />FIRE DISTRICT�� <br />PERMIT # <br />T <br />ea <br />0 <br />LABORATORY NAME . , <br />COUNTY �� PHONE # I_ �� Z <br />R <br />! <br />-e_ <br />SAMPLING FIRM <br />1 111111111111111 11111111illi <br />PHONE # tr/L . 3&,f_ rj q q <br />TANK ID # <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />1111 1111111111111111 1111 iii II 1111111111111111 <br />11 11111111111111111111 111111 11 III�IIIIIillllllll <br />L <br />_ APPROVEDAPPROVED <br />WITH CONDITIONS) DISAPPROVED <br />A <br />_ <br />SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME gG-/C <br />✓ DATE /7 <br />11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />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." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />TITLE L_:1%i�'c'l�.,� DATE <br />CONDITION(S): v ®�j?A/� A r'/ �'- r�r°'-`i i/ Gr�j or' G•o �, , J <br />EH 23 046 (Revised 7/10/96) Page 3 <br />