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010 <br />m <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVMONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TE=MPORARY CLOSURE OR ABANDONMENT IN ?L:C= 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 />EPA SITE R <br />F I FACILITY NAME <br />C •I ADDRESS C? Q <br />i <br />L I CROSS STREET <br />I <br />T I OWNER/OPERATOR <br />Y ✓V <br />! CONTRACTOR NAME <br />0 <br />4 CONTRACTOR ADDRESS <br />T <br />R I INSURER n /D <br />;TRE DISTRICT / <br />T <br />0 i LABORATORY NAME <br />R <br />00114030 �I ? 1 PROJECT CONTACT i TELEPHONE T rs p ��C�_ <br />nn � 'T 0 ` (�� t ; PHONE <br />Yl w ..ivt itA 1 /9 /1/t 1. 6 1 `a <br />PHONE <br />Zog- 9�f3-.tall/ /,Zc <br />?HONE <br />35 �/I ! CA LIC 0 cass� <br />WORK.CCMP.R �C�.s®o <br />%1il%L.f� r v s r t rii� <br />PERMIT T <br />COUNTY <br />PHONE 4,g11l — 7qQ - <br />PHONE R <br />L_13 <br />WA <br />t11It1111I111t11U{t11it1t1l1111tti!!ll{{ii[I111111I111!1lltitlllltiltllIlltlltltlttilttittttilli[lllllilt111111111It1ttttlil <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, 1 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 SUBCONTRAC'.iNG SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />r-nMocusATTrnu I AWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />CONDTTION(S): 4— --� lt«.v '�- M ` zZoO <br />rz. 0 <br />ZD j - � <br />SEP 11 1998 <br />EH 23 046 (Revised 9/1;1/96) Page 3 <br />�4 <br /><W <br />i/ ° E .,- <br />SAMPLING FIRM <br />/J tti`AA„Li11or�/1/V1 0i <br />j17 1 —7M /vUIO <br />11 liittlllIlllltlitllllll[lltt <br />CHEMI C.1LS <br />S- R CURRENT /PREVIOUSLY DATE ST INSTALLED <br />i <br />TANK iD <br />r <br />TANK SIZE <br />39 <br />4000 <br />s e <br />T <br />39- <br />O O <br />t <br />A <br />39- <br />®e <br />4 <br />39- <br />K <br />39- <br />39- <br />39- <br />l1111!!{{111111111111111111!!11!!l11111111111l111 <br />11{lllltt11111!lllitit11111{ltltllllli1tt1111 <br />P <br />iltlll{ill!{I111111II111t11111 <br />APPROVED 14,_ APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />- <br />A <br />PLAN REVI=W <br />(SEE C OITI NS 3EL0W AND/OR ON <br />_=Z'S NAMEV� C <br />ATTACHMENT) <br />DATE 2 <br />Q <br />t11It1111I111t11U{t11it1t1l1111tti!!ll{{ii[I111111I111!1lltitlllltiltllIlltlltltlttilttittttilli[lllllilt111111111It1ttttlil <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, 1 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 SUBCONTRAC'.iNG SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />r-nMocusATTrnu I AWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />CONDTTION(S): 4— --� lt«.v '�- M ` zZoO <br />rz. 0 <br />ZD j - � <br />SEP 11 1998 <br />EH 23 046 (Revised 9/1;1/96) Page 3 <br />�4 <br /><W <br />i/ ° E .,- <br />