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SAN JOHQUIN COUNTY PUBLIC HEALTH SaRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTAV4PORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL CAT=-. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br /> REMOVAL ❑ TEMPORARY CLOSURE Cl CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA S[TE x CAL J'6009PROJECT CONTACT V%0-0146 SIA ?HONE# <br /> FACILITYNAME S k . 'C- PHONEa -z.v�i- - l <br /> ADORESS '312,1 zll`- IR a <br /> CROSS STREET uja <br /> OWNER OPERATOR �� {Zi PriONE.� zv' R' 3 - (031Z-- <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Y CO til -�� .eL-R1 V.0 An PHONE# `IZ �S3i <br /> CONTRACTOR ADORESS -] IM �L^e 1 J111 CA UC x ( �3 CLASS 9 z- <br /> INSURER ti-Nq ( III VZ-a txc In C6 - RKERCOMPC WG ZClrj 'S l 1&1�;- <br /> FIRE DISTRICT c.11 St C K O r, PERMRt I I'- <br /> LI ABORATORY NAME CC 1.1 �. COUNTY PHONE;f <br /> SAMPUNG FIRM PHONE t Sc7 vl <br /> TANK INFORMATION <br /> TANK 10 0 TANK SIZE TANK CCN7'ENTS PRESENT 3 PASA DATE INSTALLED <br /> 39- eoc�c) q a l waste cs AL i SSS <br /> NL <br /> 39- � <br /> 39- <br /> 39- <br /> 39- <br /> APPUCANT MUS PERFORM ALL WORK IN ACCORDANCE WITM SAN JOAOUIN COUNTY CRDINANCES. STATE LAWS, FEDERAL IAVYS,AND RULES AND <br /> REGULATIONS OF SAN XAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTtnFS THE f0U_OMNG: <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR`MIICH THIS PERh/4T IS IS$UED,I SkAIJ,NOT EMPLOY AW PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKERS COMPENSATION LAWS OF CAUFORNIA' CONTRAC•'OR'S mmNG OR SUBCONTRACTING SIGNATURE CERTIFII:$ <br /> THE FOLLOWNG: I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TKm PERMIT IS I$53IEO-I SHALL EMPLOY PERSONS SUBJECT TO <br /> 'NORKER'S COMP- iA710N LA OF CAllf-0NNUI' <br /> APPUCANT'S SIGNATURE L TITLE kA ti I Ikl.cS l S 2 " OATS_ <br /> Q.APPROVED ID APPROVED WITH CONDITION(S) Q DISAPPROVED <br /> (SEE CONDITIONS BELOW AN=R CH ATTACHMEN7) <br /> PLAN REVIEWER'S NAME - DATE <br /> ANY DEVIATIONS FROM THM APPLICATION MUST BE SUBMtTi'ED TO EHO FOR APPROVAL PRIOR To COMM04Q WORK- <br /> ; CONDmONS: <br /> �I <br />