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0 0 RECENED <br /> ENVIRONMENTAL HEALTH DEPARiMON' <br /> ENVIRONMENT HEALTH <br /> SAN JOAQUIN COUNTY PERMIT/SERVICES <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 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 --T-- IPHONE# <br /> ADDRESS N c6.c- '7^oti e (ZA 21 <br /> CROSS STREET <br /> OWNER OPERATOR IPHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Ch e Y eS n+a Go PHONE# 2/;- 3oS'171`U <br /> CONTRACTOR ADDRESS O S• 1 CA LIC# CLASSucv <br /> ffttZ N3Is <br /> INSURER fr e7o WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY IPHONE# <br /> SAMPLING FIRM PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 1 121060 <br /> 39- /2 O o o U P�- <br /> 39- '2 00 f-� I/P,I ee A-d <br /> 39- 20 oOo I g)I ef-eer <br /> 39- 2,01000 eJ.,-eset- <br /> 39- '�I0 000 1 A/ese /- <br /> APPLICANT <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_ ear✓I S L)1 DATE_j 6/!?� <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 />