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a <br /> D <br /> 0 <br /> ENVIRONMENTAL HEALTH DEPART NJF <br /> SAN JOAQUIN COUNTY 2008 <br /> ENVIRONMENT HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSUREIPEgMM <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT ==PHONE# <br /> FACILITY NAME _-r- IPHONE# <br /> ADDRESS gOt. Toa g- �� . ®� a2y <br /> CROSS STREET <br /> OWNER OPERATOR / PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME ch a rlev _ • PHONE# 2/3- S'' <br /> CONTRACTOR ADDRESS ® S• /rn q I CA LIC# 30 9,0 1 r I CLASSCI0 (- <br /> 'P t3,t3 <br /> INSURER dD,l WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY PHONE# <br /> SAMPLING FIRM PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 0 tJn Ge <br /> 39- �2 o V u e <br /> 39- 2 00 to t1wl ee. <br /> 39- 1000 ,e.)®es-et, <br /> 39- ovo o®-es-ec <br /> 391 D0 000 A,ese/, <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE_ _ _TITLE e/r VI's v/ DATE__ <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 APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046 (Revised 12/31/07) 3 <br />