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SAN JC ZUIN COUNTY PUBLIC HEALTH �,,.RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br /> Cl REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# , 0F'"! PROJECT CONTACT - ( Sup .7 C PHONE# - <br /> FACILITY NAME PHONE# G ' <br /> ADDRESS I cc, rtYi'PZ.. <br /> CROSS STREET 'I L' , "� <�NZ <br /> OWNER OPERATOR V7 - PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME G /T �. N L>c H G t I PHONE# <br /> CONTRACTOR ADDRESS ` Q g �Q fj/ CA LIC# LCLASS <br /> INSURER WORKER COMP# lc/?, <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME �+ uG i G_— ✓�.A" -1�( COUNTY t:c fp Jct PHONE# - �} <br /> SAMPLING FIRM J,fa i�'K 1 iv -Icun (io nc�( PHONE # G 'E� <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED <br /> 39- fir.!J / 2a <br /> 39- O -07 bji�x�'-oec1 <br /> 139- <br /> 39- <br /> 39- <br /> 139- <br /> APPLICANT <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <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 CALIFORNIA.' n <br /> APPLICANTS SIGNATURE o4 A,C+ X;I�' TITLE �`A Ic,l�e'� lb,GAaLV ! DATE <br /> ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> 4SS�E,E CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE e- <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 6 <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />