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SAN JOAC OIN COUNTY PUBLIC HEALTH SE,,,.110ESC U PJ\Y <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR <br /> OUS <br /> NCES <br /> STORAGE TANK S)EXPIRES 90 DAMS OFROM HE APPROVAL DAOPLACENMENT IN UNDERGROUND <br /> TE DO NOT WRITE N ANY SHADED AREAS. NI DIICCATE PERMITATYPE. <br /> ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITEq PROJECT CONTACT 77� PHONE# (�o a ro• - ^`�I <br /> PHONE# 24j.-.2 Ph <br /> FACILITY NAME <br /> ADDRESS 1153o that 4, <br /> CROSS STREET AIH m <br /> PHONE* <br /> OWNER OPERATOR <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 61 ^ 70.. PHONE# (9.� rP xR-s�s� <br /> CONTRACTOR ADDRESS P.O. c o A A2 CA LIC# - - CLASS <br /> INSURER SIvLeCe... WORKER COMPO jg1ji - 4K onLt <br /> en 4:w <br /> FIRE DISTRICT 5,, m1 - [:.e PERMIT# FrIP-41800 <br /> 4 <br /> LABORATORY NAME a L no: COUNTY Ye to PHONE# 330 -1ST -o°Izo <br /> SAMPLING FIRM -Tla PHONE # y� In _i4 <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS(PRESENT 6 PAST) DATE INSTALLED <br /> 39- -rA1 eeo <br /> 39 -ra L4 mc <br /> - <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT 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 AGENT'S 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 TOR'S HIRING OR <br /> CTNG SIGNATURE CERTIFIES <br /> THE FOLLOWINGME ,E CERTICT TO FY THAT IN THE PERNSATION FORMANCE O MANCE FOF CALIFORNIA.'THE WORK FOR WHICHHTHIS PERMIT ISSUED.I SWLLL�EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CAUFORNIA- <br /> APPLICANTS SIGNATURE La-Z =Z— TITLE M. +- DATE 11 Dom'". 2Y <br /> O APPROVED APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME /J DATE!/_ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> q klY�-.,�� ' 7h Sihmir� fU <br /> 14m-fiA k, <br /> r <br /> 7hz n-molKtgf jrV %ce -1-0 be U�() fLLnk tLl/ bz G`Minirn <br /> / 3DIFx/�/��1000 /NUOT- 2(�I(o61111000. <br /> (CJ) -iCUbMIT PGT -I to I%5 OITI'G2 s,ejroi) Ay ��•-„ LY <br />