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Environrrga, iai� ho., w_ D6pa4ntsaNlaAQuI , -I' G <br /> I <br /> — COUNTY- <br /> 2018 <br /> APPLICATION FOR UNDERGROUND STORAGEITAI K"I lI,Ar-- l`1I [\f <br /> CLOSURE PERMITI <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. <br /> INDICATE PERMIT TYPE: <br /> %REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT L- ' � j" ti'}'j �� L:� fPFiONE# Z ! y� <br /> FACILITYNAME " V3'il�ll '� ...•- {/'V�1 ZV� PHONE # <br /> ADDRESS _ V� ' I•., I i <br /> CROSS STREET] V� - L) T11.17 `v <br /> OWNER OPERATOR HONE ' �5 ^ 0 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME !' 'V4 Ti SZ? { e� PHONEY r •5 . �( 7 <br /> CON TRACTOR ADDRESS �• i . G'J C�' f , 1� CA LIC # L'� } -JL1 iLj CLASS <br /> INSURER w _ Y 'YV�Y"�TZ.� L=�'�+ WORKERCO C.t: A 'i:j: C 4 <br /> FIRE DISTRICT - } % , i C. PERMIT # <br /> LABORATORY NAME 4 -:SAA'? , '� I (' :C;aA COUNTYE <br /> SAMPLING FIRM c s e'�Y A-,j PHONE # L Z <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TA K CON. ENTS (PRESENT .AND PAS , DATE NSTALLED <br /> 39- Q V , � G � Com' NVL "d k ` t <br /> 39- <br /> 39- <br /> 39- <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 ENVIRONWNTAL HEALTH DEPARTMENT, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 41 CERTIFY THAT IN THE PERFORMANCE'QF 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'$ COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i SHALL <br /> EMPLOY PERSONS SUBJECT TO WGRKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANTS SIGNAFGRE` . _. ' 46 TITLE '�'J1 1'VIN j �J) 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 /> 3 of 10 <br />