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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE: <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE 0,pLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# 000 211 PROJECT CONTACT A G. FE I dc-,( PHONE# Z0 (CA <br /> FACILITY NAME G6C L C N PHONE# <br /> ADDRESS' 1-71'7 IV CTr V O C FJ4 f ff A Ve. H41ulWcA. C 3 <br /> CROSS STREET S 14,94 C <br /> OWNER OPERATOR I<A I f N VL PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME S Vf IS U 10 f 12 16 A. ()X' " S6 R,V If G PHONE# '?2 S- <br /> CONTRACTOR ADDRESS P. O. gdeX ll I'I I CA LIC# 1.3 CLASSA 13 r Z I fE�Z <br /> INSURER C"fiaWORKER COMP# Zb <br /> FIRE DISTRICT TJ'r C PERMIT#rS .4fA C*CLL C 6 AA <br /> LABORATORY NAME C I-5 L-4 S COUNTYsEAcA I 6;i im PHONE# i.- -?3a <br /> SAMPLING FIRM Off. WC. PHONE# Q 2V- <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- 000 <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA! CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT T ORKER'S COMPENSATION LAWS OF CALIFORNIA.' �\ <br /> APPLICANT'S SIGN TITLE L )k­lV-QX-C_. DATE Z ► <br /> ❑ APPROVED O APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 07/22/10) 3 <br />