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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN J OAQ U[N COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT1TCEMPORARY C3_C LUURE OR ABANDONMCNT IN PLACE QE UNDERGROUNO'HAZZARDOUS SUBSTANCES <br /> STORAGE7REMOVAL <br /> ' <br /> S)EXPIRES 18013AYS FROM THE APPROVAL DATE_ 00 NOT WRITE IN ANY SHARED AREAS. INDICATE PERMIT TYPE:' <br /> ❑ TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE tf I PROJECTCONT CT O`fCc <br /> FACILITY NAME C I ANi ow ' PHON # 'A �y <br /> 6ftO,;S STREET A _ _......-—- <br /> QVINER OPERATO PHONE <br /> CONTRACTOR INFORMATION <br /> u ;v i3Ac roR rtaM1: II gal _r1 �,c _ <br /> PH F.# `l! '7„3--7770 <br /> t 2Z-/ CLASS 31..CONTRACTOR:ABDDRESS P- �— <br /> ,5 <br /> INSURER c WORKER C-oMPrr <br /> _ - - <br /> FIRE.of TrIcT " e/` %zz� /-i rzi_ PERMITA l,3 -2O`t -��•�/- i'�333"pc> "j�'7 <br /> L.A30RATORY NAME �t G. GPS - CUUNTY 14 <br /> St�Ad1'LING FIRM <{' PHONE 'v4 <br /> TANK INFORMATION <br /> TANK 1D TANK SIZE TANK CONTENTS PRESFNTAN _PAST} b ITE IN ALL D <br /> 1. <br /> .. — I e r vim;0� <br /> 3.9- <br /> JJ n(� ^t' -------��� ri Zt J'f <br /> 3 9- its, /-.y f[,j r,� - ---..-....---• <br /> r <br /> APPLICANT MUST PERFORM ALL WORK IN ACCGRDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAINS,FEDERAL LAWS,AND RULES AND <br /> RF-GUTATIONR OF SAN JOAQUIN GOUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LiCCNS1=1)AGENT'S SIGNATURE CERTIFIES The <br /> )`Qt.I OAORQ! `I CERTIFYT€-IAT IN THE PERFORMANCE OF Tt(l WORK FOR WHICH MIS PERMIT IS ISSUED,I SHfiLL'NO-r WPLOY ANY PERS04 IN SUCH <br /> A I,AANNr-R AS TO BECOME SUBJECT 'TO WORKER's CII'ff'NSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR-SUBCONTRACTING <br /> SICzNATU12E CERTIFIES THJ= FOLLOVtgNa 'i CERTIFY'I1�AT IN THE PERFORMANCE OF THE MONK FOR V4Vii1011'11118 PFRMIT IS IS;LIED, I SHAD. <br /> EMPLOY PEn^^SONS SUBJLOT TO WORIfF.R'S CUtriP�N3AUM L4V%la OF C 1FORNIA.' <br /> 'm er z <br /> APPLIt,ANT'8.�SIi NATUTRE TITLE <br /> 9 DATE- <br /> } <br /> r <br /> I�E`7. APPROVED r PPROVED WITH <br /> CONDITION(S) � C�I�>�I]P�tOVED <br /> . �'i CON oNs aELow ANaspir oN ATTACI IIv EIJ'T) j <br /> ULAN REVIEWERS NAME DATE J J9 H <br /> ANY DEVIATIONS FROM THIS APP.L ' TION MUST•8E SUBMITTED TO EHD FOR AWROVAI-PRIOR T4 COIVIMENc C:HVC}RK. <br /> t CONDITIONS4 <br /> .f:1- 23 046 (Revized 10/30/12) 3 <br />