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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BE : <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />1 <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY NAME <br />PHONE # <br />A <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR <br />R <br />PHONE # <br />Y <br />C <br />CONTRACTOR NAME&L S C04 Sr <br />PHONE <br />NCONTRACTOR <br />ADDRESS <br />goo��D�o DI2D-r <br />LI # <br />700 <br />CLASS :2G Z! <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT I t)Af I IIIPERMIT <br />#lir— <br />T <br />0 <br />LABORATORY NAME SL Q\&b(14 �A,-4T,4V, D <br />aU`l <br />PHONE # Q Q <br />R <br />SAMPLING FIRM /Y��j � (.N�l 0!J bAI <br />PHONE #!�� Gf z0 �Q(P <br />TANK ID # TAN IZE <br />CFI MICALS STORED CURRENTLY/PREVIOUSLY DATE UST IN TA LED <br />39- I D <br />DLIWO- <br />P9 1&#A twin <br />T <br />39- A o <br />'- <br />A <br />39- <br />NIMtOv� <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />p <br />L <br />APPROVE APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />( E (ATTACHMENT <br />WITH CONDITIONS) <br />14A� <br />N <br />PLAN REVIEWERS NAME <br />DATE 4/15( <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN <br />COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I <br />SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />f� <br />��tl\/� T"� <br />j� Q <br />1�✓/ <br />APPLICANT'S <br />SIGNATURE: <br />TITLEQ <br />DATE / <br />1 <br />EH 23 046 (Revised 4/26/94) Page 3 <br />