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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />E4 23 046 (Revised 9/11/96) Paye 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # goo- E. A4407cy ZOq 9.s6'DZ6# <br />F <br />,q <br />FACILITY NAME i&f 4�T /� - . f- P <br />PHONE #'704¢lZ- <br />A <br />C <br />ADDRESS 3535' <br />L <br />CROSS STREET q 9 NEGa'7aU ,e%%, <br />I <br />T <br />Y <br />OWNER/OPERATOR -- -. PHONE # <br />CErcrf/Nl, CEecI+lvl 6 G/ov�VuoN/ S!D - 75�%Zo58 <br />C <br />CONTRACTOR NAME �Idva.�ce� EjjV//-�lN�'r7�C �/ic' PHONE ; ypq y,,G-o16'fl <br />0 <br />N <br />CONTRACTOR ADDRESS j86 g Nar 1—,2,*A/� <br />CA LIC # 68l)'z2% <br />CLASS �. <br />R <br />INSURER �� D `YQ�7LIJpN rj /'-jam WORK.CC-P.# �3i �4�4-95 <br />A <br />C <br />FIRE DISTRICT hJ�}�i'�(Ja //YJ�jQ./P'DA' I PERMIT # <br />T <br />0 <br />LABORATORY NAME Aj.P#; .4.V,,445/T/G/r[ COUNTYNja),VUAJIJ PHONE X 7,07 168 O4 -e <br />R <br />i SAMPLING FIRM If Pl;// AW/&14/%ri'-f PHONE 4 7.07¢d0rQ4'b1 <br />TANK ID # TANK S12E CH IC,ALS STO D CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39-Bfl%i <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />TM/410 <br />K <br />39- <br />39- - <br />_e <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />p (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N � <br />PLAN REVIEWER'S NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1-1 CERTIFY THAT 'A <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:' <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />SIGNATURE: TITLE /i�QI�97 GATE 4-11-17 <br />APPLICANT'S <br />i <br />CONDITION(S): <br />E4 23 046 (Revised 9/11/96) Paye 3 <br />