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1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV MONME.VTAL HEALTH DIYLSION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNIIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANOONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />' EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 HOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />' EPA SITE * CAr L 00117 131 a- PROJECT CONTACT L TELEPHONE $ <br /> Q v^ u r.% <br /> F FACILITY NAMErYpwkS QVIe- S+p PHONE 'J` i209'- 39- 9575 <br /> A <br /> C ADDRESS 207;. W Yos ",le ve /14a.t4eca- CAjj-t 95337 <br />' [ L <br /> L CROSS STREET <br /> A,,r {•r fit}Q <br /> Ipo <br /> T OWNER/OPERATORLL PSE 9 q <br /> Y FIGlr //'•� F {_ILII K <br /> CD I CONTRACTOR NAME r1-f 1YL.�C TTDvI �►1 G PHONE 9 '707-14$-J _ S.Jf <br /> H CONTRACTOR ADDRESS f 102 D 0 J C ��. Vaso V S-c [ LI c -]y 19 q 5 CLASS g G 5 7 �S$ tk�1- <br /> T <br /> R INSURER T� 1BuCkKQ.+- GroupI WORK_C'OMP.IR /�/ <br /> A yy�� I <br /> C FIRE DISTRICT CA 0 Moi• ecQ f' ,,c U T PERMIT 3 qg.3 0 <br /> T <br /> O [LABORATORY NAME M G w <br /> R b e 1 COUNTY PHONE * 5710 --719 - 16;.D <br /> SAMPLING FIRM Re--wd'Y �CL l PHONE x 7a7_ q5j _%r•bb <br /> lffilllJlllll11i111J1I11(IIIII • .-,•. �-I3 <br /> TANK IO 0 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- TAi4i4ot 10 000 <br /> T 39- �aoa ,�gl• <br /> A 39ko 0A- <br /> I K 39- — <br /> K 39- 0 to e o e , <br /> 39- Id 000 <br /> 39- <br /> I Jill J <br /> 9-!Jill! I I I I III1 ( ! l l fl l ifll 11 lllliE <br /> L APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE TIONS BELCH AND/OR ON ATTACHMENT) <br /> N _ _ <br /> PLAN REVIEWER'S NAME S�� DATE SI <br /> ll1IlIII11111111J111111!(1111(llllilll(111111((lllll((111(I111li1i(11111111((1lllllll(I(11((I((lIl(lillil[I1111(III11111I1111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAYS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON III SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWSCALIFORNIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING <br /> "I CERTIFY THAT IN THE PERFORMANCE T WOR FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAYS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLEylLe DATE <br /> CONDITION(S): t) � 10E `1Za,�.`o �u�� SDE Lb5 IOtb�a�� � <br /> 2) SPS;act N\L C:Or►�, b f <br /> �4 <br /> 4)-T ke Kvs4- 6 a ow-4- <br /> b� �,3oaSL. MN—s•E- 6a C-& , c. b4 6l_2.(,jS �} ;s Fc .{�,ak 4J:i�s�Ls� <br /> . _ �_ ..� �.,,.. _,_ .�ti�� •-rt..o�� � o�icouE anon 5-4a��-c�.-�girds �r! �e M� <br />