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SAN joAquIN Environmental Health Department <br />COUNTY <br />AFFIDAVIT OF FACILITY CLOSURE <br />Facility Name: <br />Facility Address: <br />Facility CERS ID: ob �� 1 T-7 <br />Facility Closure Date: <br />Current Site Owner Contact Info: <br />New Facility Location (if relocated in SJC): <br />I, the undersigned, hereby affirm the following and attest that all the information is true and <br />correct: <br />1. 1 am the owner/operator or an authorized representative of the above-named facility <br />2. The facility ceased operations at the above location <br />3. All hazardous waste, hazardous materials, and any residual contarniqation vyere removed <br />from the site and transported off-site for proper disposal on r <br />in compliance with all applicable local, state, and federal regulations. <br />4. All required closure activities have been completed, and final waste records and other <br />supporting evidence of site closure (site photos, etc.) are attached to this affidavit. <br />Signature: OWMAt <br />Printed Name: 'VL�_1 <br />Title: 0 W VL'C V - <br />Email and Phone Number: 4'S�s i" <br />Date: 1_1� 13.0 <br />I Of 1 <br />