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SAN JUIN COUNTY PUBLIC HEALTH VICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY 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 <br />�1 <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />EPA SITE <br />PROJECT CONTACT ` .; �?;<.4����' PHONE# 7;q <br />ITY NAME <br />;7j4 PHONE -O D <br />ADDRESS <br />�7T <br />CROSS STREET <br />L INI GL/k L <br />OWNER OPERATOR <br />WE�JT Ctfq l P,Z&Pr-Rl1ES PHONE # <br />TANK INFORMATION <br />TANK ID # <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAMEr/<JNC,-, <br />©en -9 e <br />39- p <br />PHONE # T % lOG4� <br />CONTRACTOR ADDRESS <br />L INI GL/k L <br />�77-&CA LIC #G, f D �Z? CLASS <br />INSURERtj <br />39 - <br />WORKER COMP# <br />FIRE DISTRICT <br />j/GrAqr <br />A <br />PERMIT # -rFA <br />LABORATORY NAMECOUNTY <br />PHONE # OrI B <br />SAMPLING FIRM <br />gj(J <br />AAA, <br />PHONE # d7 <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- p -p Z <br />©en -9 e <br />39- p <br />(p a lowG/m;7 <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "1 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br />APPLICANTS SIGNATURE <br />TITLE-f—/��/� u� 4 • DATE IIZ 0 <br />❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE <br />ANY DEVIATIONS FROM THIS APPUCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />C 7 � S� <br />Z. <br />EH 23 046 (REVISED 10/19/98) Page 3 <br />