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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TENIPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE; <br /> REMOVAL ❑ TEMPORARY CLOSURE (� CLOSURE-IN PLACE <br /> 10 Ram r <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT ", c° .t C, k Q PHONE# 'o' ' � L, rl j j <br /> FACILITYNAME PHONE e Lha <br /> ADDRESS <br /> CROSS STREET 'Zwhmv <br /> ? <br /> OWNER OPERATOR Q11' PHONE#V-0 c.7�,/2 <br /> CONTRACTOR INFORMATION �J <br /> CONTRACTOR NAME A hulrbAn%e64tJkj 111 S PHONE# -(j 5g <br /> CONTRACTOR ADDRESS CA LIC# Gl 150 CLASS <br /> INSURER -n WORKER COMP-9 <br /> FIRE DISTRICT i)1� iF- > Cxt_ /" .11 PERMIT# <br /> 1 LABORATORY NAME 6tl.4, ,44 Y 4-' ' <br /> COUNTY S .9 S U< PHONE#ZG? 1Z"C'lG'l1 <br /> SAMPLING FIRM [;��, a� !Ci r' >!�. TC ._ PHONE # 7 , <br /> TANK INFORMATION <br /> TANK 10 TANK SIZE TANK CONTENTS PRESENT& PAST PATE INSTALLED <br /> 39- <br /> Fiz, 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUS-PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROIN:.,\CES,STATE LAWS,FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED .:GENT'S SIGNATURE CERTIFIES THE FOLLOWING .I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERIMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOL LOWING: 'I CERTIFY THAT 4N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.t SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS <br /> AOFFCCALLIFORNIA..'y�� 1 l/ <br /> APPLICAN'T'S SIGNATURE } I/Wl .���/y/r-�-/\ TITLE. A�I`GS%GfP' DATE <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE; <br /> i <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> C771NS- <br /> Or I <br /> EH 23 046(REVISED 08113/99) Page 3 <br />