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SAN J(.,,AUUiCOUNTY PUBLIC HEALTH `RVI S <br />ENV NMENTAL HEALTH DIVISION 1p <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND t1AZARD S SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. IN TE PERMIT TYPE: <br />,REMOVAL Cl TEMPORARY CLOSURE ® �OSURE IN PLACE <br />A <br />NAME <br />CROSS STREET <br />OWNER OPERATOR <br />CONTRACTOR NAME A <br />CONTRACTOR ADDRESS <br />INSURER — PC <br />FIRE DISTRICT e <br />LABORATORY NAME Al <br />FACILITY INFORMATION <br />PROJECT CONTACT',,:.'�:>' <br />f'! <br />CONTRACTOR INFO <br />PHONE <br />_PHONE # <br />TION <br />I PHONE 4 <br />f,OVA) CA I CA LIC # (OVO G r <br />ORKER COMP# <br />PERMIT # TSI' <br />COUNTY MPHONE # <br />PHONE x 707 <br />TANF</INFORMATION <br />T NK CONTENTS (PRESENT & <br />muflol <br />CLASS <br />TE INSTALLED <br />APPLICANT MUST PERFORM ALL WORK IN A ORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. FEDERAL LAWS. AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY BLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br />CERTIFY THAT IN THE PERFORMANCE OF E WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S CO ENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: '1 CERTIFY THAT IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF UFORNIA.' / h <br />4—r� —1* <br />APPLICANTS SIGNATURE2�" TITLE t/'�UAGATE /z <br />❑ APPROVED CHAPPROVED WITH CONDITION(S) ❑DISAPPROVED <br />i (SEECONDITIONS BELOW ANDIOR ON ATTACHMENT) <br />PLAN REVIEWER'S E �M�u./„��✓�—' DATE-)— <br />ANY DEVIATIO S FROM THIS APPUCATiON MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: ,, <br />10/1 <br />