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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # PROJECT CONTACT & TELEPHONE 9 <br />F FACILITY NAME PHONE # <br />A <br />C ADDRESS <br />I <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR PHONE # <br />Y <br />C CONTRACTOR NAME <br />'PHONE # <br />0 <br />N CONTRACTOR ADDRESS <br />=CA <br />LIC # <br />CLASS <br />T <br />R INSURER <br />WORK.COMP.# <br />A <br />C FIRE DISTRICT <br />PERMIT # <br />T <br />0 LABORATORY NAME <br />PHONE # <br />R <br />SAMPLING FIRM <br />PHONE # <br />tl!!llltllltiltli!lllllillllll <br />TANK ID # <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P 1111 <br />L APPROVED <br />D WITH ITION(S) DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME <br />nlunurnniuln <br />DATE <br />lira <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERF CE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TOWORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TOWORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE <br />EH 23 046 (Revised 7/10/92) Pap 3 <br />DATE <br />