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r j � <br /> 4 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE T <br /> APPLICATION FOR PERMANENT/T T IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOWt <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE / PROJECT CONTACT t TELEPHONE # 0921- <br /> F <br /> 9 _F FACILITY NAME 5 ` PHONE 0 a•p <br /> A <br /> C ADDRESS /• ZCS. <br /> t <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE ! <br /> Y �A c fc �oS-� 2 - -06 y, <br /> C CONTRACTOR NAME S PHONE >x <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC S 3835, Q CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTRICT waiwtT R <br /> T <br /> 0 LABORATORY MA14E PHONE I <br /> R <br /> SAMPLING FIRM LPHONE ! <br /> Iltlitltlllltilttlltllt t t <br /> 39- <br /> SANK ID 0 TANK SIZE CNEMtCAL STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> tltl <br /> L }C APPROVED APPROVED WITH CONDITION(S) s� DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> Itllllltlttllllllitt 11111 <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- 01 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 CALIFORNtA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING- <br /> "t CERTIFY THAT IN THE PERFORMAINE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER-S <br /> COMPENSATION LAWS OF CALIFORNt . <br /> APPLICANT-S SIGNATURE: <br /> TITLE IZ7-��- " DATE <br /> EH 23 046 (Revised 7/10/92' Page 3 PAYMENT <br /> RECEIVE( <br /> FEB 0 4 1993 <br /> SAN JOAQUIN COON rY <br /> PUBLIC HEALTH SERVWES <br /> ENVIRONMENTAL HEALTH Ui-v,SION <br />