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Ll <br />SAIN JOAQUrq COUNTYPUBLIC HEALTH <br />ENVIRONMENTALHEALTH <br />-PPLICATIOIN FORUNDERGROUND STORAGEt <br />THE PERM17 FOR ?ERMANENT/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 />REMOVAL TEMPORARY CLOSURE CLCSURE IN PLACE <br />EPA SITE #C o o l y o3 o L4S PRCJE T CONTACT TELEPHONE f1 (/ ZQcl - AO! - t�•13,7 <br />+ t .Y <br />F FACILITY NAME (i i N ?HONE <br />ADDRESS 9E 2 j��_ r <br />CROSS STREE- _ J <br />OWNER/OPERATOR PHONE ' ! <br />Y Zo5- 9�3-.2a�1 lzo -A177- <br />CON T RACTCR NAME PHONE Q 461 ® b 33 7 <br />N CONTRACTOR ADDRESS CA L... Q� ....ASS <br />a i INSURER j'-^�'�� 1 WORK.CCMP. 47- 9� <br />FIRE DISTRICT PERMIT T <br />0 LABORATORY NAME COUNTY PHONES/ a <br />R / (® <br />SAMPLING FIRM ` PHCNE <br />tlltltlllllllllllIltlllitllf tl <br />ANK iD 'ANK SIZE CHEMIC"LS S' R CURRENT /PREVIOUSLY DATE 'ST INSTALLED <br />39- O Q OCi A <br />39- D®OI A°1 <br />A 39- <br />N 39- /f) ®® ® a t <br />K 39- <br />39- <br />39- <br />1{illtiltl[tllll[litllt[lllltl tlltllllittlltllttlftt1111itllllClllltltltltlilttlltltfltltltillttlllitllltlttitilttt[lltltitl <br />! APPROVED �_ APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEEDi TI NS BELu.d AND/OR ON ATTACHMENT) <br />H t <br />PLAN REV I EWER' S NAME'" pd_ DATE 2 cFS i 2s <br />i <br />illtttltflltltlllllltllllltlllfllltlltliltlttil{lull{tllttl[ttllllt{tttllltlttll11t1titlllttiliititlilltt[tlttttt(tlllllltll <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OFF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR !ICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11I 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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />' COMPENSATION LAWS OFF CALIFORNIA." <br />I <br />/(�4 <br />APPLICANT'S SIGNATURE: TITLE DATE l <br />I <br />CO.NDMON(S):F2'&o <br />LA4-- <br />z- ld� _ <br />EH 23 046 (Revised 9/11/96) Page 3 <br />