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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTAN9E STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE P MIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE - <br />EPA SITE # PROJECT CONTACT & TELEPHONE # <br />F FACILITY NAME/rY �� PHONE <br />A <br />C ADDRESS ` l <br />I <br />L CROSS STREET <br />T OWNER/OPERATOR PHONE <br />Y <br />C CONTRACTOR NAME, PHONE # <br />N CONTRACTOR ADDRESS Q�2 i CA LIC #� CLASS <br />T <br />WORK. COMP. # <br />R INSURER p'Y C/C �tIC <br />A <br />C FIRE DISTRICT PERMIT # <br />T <br />0 LABORATORY NAMEI n PHONE # <br />R <br />SAMPLING FIRM PHONE # <br />- lil[lIIIIII!II111111![lilll <br />- TANNK,K ID r. 101T piE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T 39- 'LL rr <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- T <br />1111 <br />P , <br />L V 'EDROVE ITH CONDITION(S) DISAPPROVED <br />A j ,,:f�%, (S AG , WITH CONDITIONS) 0 P <br />N PLAN REVIEWERS NAME '` DATE 1 <br />lllll![llll!lIIIIIlI � Illll <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 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COHPENSATION LAWS OF CALIFORNIA." Ii / / <br />APPLICANT'S SIGNATURE: TITLE i C DATE (D <br />EH 23 046 (Revised 7/10/92) Page 3 <br />Il �jTi" j <br />JUN 0 3 1993 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />