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SAt*AQUIN COUNTY PUBLIC HEALlWpERVICES y <br /> ENVIRONMENTAL HEALTH DIVN I 1 <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 /> L REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# 'Y �.. PROJECT CONTACT v PHONE# <br /> FACILITY NAME T PHONE# 3 <br /> ADDRESS • L <br /> CROSS STREET t <br /> OWNER OPERATOR t PHONE# 7--- <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME r 6 , PHONE# <br /> CONTRACTOR ADDRESSgi�2 <br /> CA LIC# CLASS <br /> INSURER t WORKER COMP# y <br /> FIRE DISTRICT s PERMIT a# <br /> LABORATORY NAME LrL COUNTY PHONE# $ <br /> SAMPLING FIRM PHONE t <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 1 I Z <br /> 39- r ' — 03 L4 800 Nem'kti <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: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHAD.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.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS CALIFORNM' <br /> APPLICANTS SIGNATURE TITLE L =tj,_ mat. +cV' DATE I'2_- 01 <br /> ❑ APPROVED P-APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> �' . (1 I <br /> 1) (�ll +n ' '✓1 <br /> )r✓C a IGC t rx C-/,w r/ Twin L 1'r/r r2 C COY: ne rY rCrv�c\ <br /> .1 ,rte_ t ;'l�Ac° T "l <br /> How-I C <br /> EH 23 046(REVISED 10/19 8) ` <br /> y�r-s <br /> rn/ntn-,cn• °� 301hs , CvL rCco��ltens 7y�c . <br />