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SAN X`UIN COUNTY PUBLIC HEALTH ;oVICES <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> ,,6 PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> ;iORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> f0 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# ( PROJECT CONTACT <br /> FACILITYNAME - S r CAI PHONE# <br /> ADDRESS . 17 ' -Pc- <br /> CROSS <br /> 4 - <br /> CROSS STREET (- <br /> OWNEROPERATOR a/Pl e"cG PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTORCA LIC# P;,Z �# / IC , <br /> CONTRACTOR ADDRESS �� E. A CLASS <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY i <br /> SAMPLING FIR - %�.•� ,,,,, "PHONE k A - <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CQNTENTS RESENT 8 PAST) DATE INSTALLED <br /> 39 7/0/' <br /> _ r <br /> 39- - <br /> 39- r'e cxtc� <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. 1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL 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. 'I 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 OF CAU <br /> FOfYN i <br /> e� 17 - <br /> APPLICANTS SIGNATURE ' /%v" TITLE VC-- - ' _DATE <br /> ❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> /( (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) j 7 <br /> PLAN REVIEWER'S NAME DATE -2- L- <br /> ANY DEVIATIONS FROM THIS APPLJCATION MUST S BMITrED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: o <br /> 3 c. i <br /> o <br /> ! <br /> 23 046(REVISED 1011 8) Page 3 <br />