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SA N JOAQUIN Environmental Health Department <br /> ~-- 00U NTY - '-- <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERM <br /> THIS PERMIT FOR PERMANENT/TEMPORARY 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 fe.4,C00 ,31 PROJECT CONTACT/ R %/.J �fi�j9vd PHONEm Z902 3 2 91J <br /> FACILITY NAME ��� ,yJ,j1 T ?� Ritz yaAl2 PHONE <br /> ADDRESS 51 ,6 <br /> CROSS STREETL W/c <br /> aOWNER OPERATORry GQ � PHONE #70-2 SZ �a 6v <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME &2 ?r; p AZ 41! PHONE # 2 <br /> 0J <br /> CONTRACTOR ADDRESS X 3, 57 CA LIC # CLASS <br /> JOIIB <br /> INSURER l,//� lGfl f /�S/!iZ nIC,t WORKER COMP# T NJ <br /> FIRE DISTRICT C/ ! 7 PERMIT # <br /> LABORATORY NAME c$ L`D ,iJ�L TJCG COUNTYS* 4) / PHONE # Zo9�6l�' - O/O <br /> SAMPLING FIRM 4"Ar— g* 4AJapof Z ;'�Igf.4e PHONE # <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTEPRESENT AND PAST DATE INSTALLED <br /> 1 .39 - <br /> 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 QYF� LIFORNIA." r <br /> APPLICANT'S SIGNATURE ` TITLE ! l�t7l�C � �� Oltf,��/Z 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 /> 3of10 <br />