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X <br />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 />X_ REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br />of excavation. / <br />—ooks vV)tk,5 - Alvi '!yam 4iz l�✓�i t �S <br />-��as MWt.;r�' Jo� � �CfoP-�i%tXf' �-D C'0� <br />Pi?Aj:k/1 o/uC� O�•r� � an) i ns c� � Cit S A, 11 -�A4 L5 /, 47 <br />EH 23 0" (Revised 7/10/96) W ✓ Page 3 <br />EPA SITE # <br />PROJECT CONTACT 8 TELEPHONE # Wu'TF`jk- PlfeWo - (241) 5N -q"3 <br />F <br />FACILITY NAME V AMI-- Pr-0P61¢..ry <br />PHONE # <br />A <br />C <br />/ y� <br />ADDRESS ®�jDO S • ��,C- )fVLjZ7f,,7 RL) TRAc 61 <br />I <br />L <br />CROSS STREET 5- <br />T <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />liter -*"Ay, .L11C. <br />zoij 60Y-6797 <br />C <br />CONTRACTOR NAME saim <br />PHONE # (209) 524-9653 <br />0 <br />N <br />CONTRACTOR ADDRESS 1217 S. 7th St. Modesto, CA 95351 <br />CA LIC # 449864 <br />CLASS A,B,C61/D40 <br />T <br />R <br />A <br />INSURER Calcomp Insurance Company <br />WORK•OUMP•# W964137662 <br />C <br />T <br />FIRE DISTRICT -rk*cy RukAL — dw PX.: VKR-0 <br />PERMIT # <br />0 <br />R <br />LA80RATORY NAME Geoanalytical Lab <br />COUNTY Stanislaus <br />PHONE # (209) 572-0900 <br />SAMPLING FIRM Geoanalytical Lab PHONE # (209) 572-0900 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY GATE UST INSTALLED <br />39- <br />3 <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />1)il felt <br />L <br />APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />(E E C NOITIONS BELOW ANO/OR ON ATTACHMENT) <br />N <br />�� ((�� <br />PLAN REVIEWER'S NAME .V.11 rn_ 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: "I CERTIFY THAT IN <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 COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF NIA." <br />APPLICANT'S SIGNATURE: �Y✓`CU TITLE P..(d, DATE 9-12-47 <br />CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br />of excavation. / <br />—ooks vV)tk,5 - Alvi '!yam 4iz l�✓�i t �S <br />-��as MWt.;r�' Jo� � �CfoP-�i%tXf' �-D C'0� <br />Pi?Aj:k/1 o/uC� O�•r� � an) i ns c� � Cit S A, 11 -�A4 L5 /, 47 <br />EH 23 0" (Revised 7/10/96) W ✓ Page 3 <br />