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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 gCLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#ChP,000 I 727 PROJECT CONTACT G, FE 16 C- <br /> PHONE# 107 6G <br /> FACILITY NAME ,ft5C L CIS N I*i2 PHONE# <br /> ADDRESS 1"71 W VOCiFA.7WcA C 3 <br /> CROSS STREET S'14 RA C l< Raito <br /> OWNER OPERATOR f N V PHONE# 2d 6�- Q <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME S U 'S U P (Z 6 UJr SER%/1I G 'C PHONE# q 2-T-09-7107 <br /> CONTRACTOR ADDRESS P. O. b CA LIC# 71144 Z <br /> INSURER 152k ATAC990 C.rifir 6- ( WORKERCOMP# ZD <br /> FIRE DISTRICT !Jl' C PERMIT#5 AfAr-*- � L C6f'4f2 <br /> LABORATORY NAME CL-5 L.-4 S COUNTYSACJ AW PHONE# A. X,?- <br /> SAMPLING FIRM ®C. C. PHONE# - d P lbi <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- voD l I l: S 1, <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 AGENT'S 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_J Ll� L DATE <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> { EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME J�aa DATE Q/D?F/l <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 07/22/10) 3 <br />