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•culO/zouz YJ7: a7 L674GUd4Jd FlH IN HLUUK rF1OC. ur <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKCS)EXPIRES 90 DAYS FROM THE APPROVAL,DATE_ DO NOT WRITE IN ANY SHADED AREAS- INDICATE PERMIT TYPE- <br /> 0 REMOVAL },TEMPORARY CLOSURE Cl CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITES PROJECT CONTACT _ PHONE# Q 2AS v <br /> FAOLITYNAME C1 c- RET <br /> PHpNE0 Z <br /> ADORE58 I{O51 A)cAwjrvn jlvpa Sg57D5 _- <br /> CROSS STREET I <br /> OWNER OPERATOR - Q17L 3 PHONE R4195 $ZS 66 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME PHONE# �4-i 66 <br /> CONTRACTOR ADDRESS T 1 CA LIC# 7 3Q 7% CLASS <br /> INSURER e.Cnm WORKER COMP� 7 <br /> FIREOISTRICT PERMIT# S—�p"U OPUA <br /> LABORATORYNANIE COUNTY AJ PHONE <br /> SAMPUNGFIRM PHONE 9 APIA <br /> TANK INFORMATION <br /> TANK 10 A TANK SIZE TANK CONTENTS PRESENT E PAST DATE INSTALLED <br /> 39- to asp I,n <br /> 39 <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 ANO <br /> REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. -I <br /> CERTIFY THAT#1 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SPALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER-5 COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOW ING -1 CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THI5 PERMIT IS 13SUEO.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS <br /> )OF CALIFORNIA_" (+ Q /� <br /> APPLICANTS SIGNATURErL✓U ,- PO��O.0 I�Gi7'�7�)TITLE ' YpR-/I <br /> Q IPr <br /> I OATS 11-2L.02' <br /> ❑ APPROVED 9APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> _ <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PIAN REVIEWERSNfjM DATE, ,�C!A <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 GAG(REVISEO Oeh 1199) Page 9 ' <br /> 12/10/02 TUE 09: 43 (TX/RX NO 87091 2007 <br />