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SAN JC'"O"'N COUNTY PUBLIC HEALTH P' R"ICES l 5,,,f mcam <br />Vz _NVTRONMENTAL HEALTH DIVISIl-., . y <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT / <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br />(*REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />CONTRACTOR NAME CQD <br />Goo c v PHONE # q a <br />EPA SITE # C Loo, 2 o <br />PROJECT CONTACT C I <br />PHONE# <br />Q p n as5, I WORKER COMP# 111 7 <br />FACILITY NAME <br />,,5 <br />PHONE # -707- <br />q -1311 <br />ADDRESS <br />CROSS-STREE <br />p o <br />) <br />39 - <br />ANY DEVIATIONS FROM TH15 APPLICATION M <br />OWNER OPERATOR <br />4^ K "A <br />PHONE# 737-:zYq-Z.370 <br />CONDITIONS: <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME CQD <br />Goo c v PHONE # q a <br />CONTRACTOR ADDRESS , <br />714 i 150 /) .4 CA LIC # 2Z 7 CLASS <br />INSURER cO io- <br />Q p n as5, I WORKER COMP# 111 7 <br />FIRE DISTRICT <br />C, I PERMIT # <br />` <br />LABORATORY NAME CC 1 S J �� <br />C /7 I I <br />` •, 7� G COUNTY S A N �1 y_ �� PHONE # -/ O -'1 G Z <br />SAMPLING FIRM eC <br />n o TeL t PHONE 4 la <br />TANK INFORMATION <br />APPROVED WITH CONDITION(S) <br />TANK ID # TANK SIZE I TANK CONTENTS (PRESENT & PAST) I <br />DATE INSTALLED <br />39- I -0 0. reo <br />4 <br />39- -C'Z- 1r C <br />I k� <br />39- <br />39- <br />PLAN REVIEWER'S NAME <br />39- <br />39 - <br />ANY DEVIATIONS FROM TH15 APPLICATION M <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 AGENTS 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNARIRE CERTIFIES <br />THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA' <br />APPLICANTS SIGNATURE /1AVL� \I.n A�I�_ TITLE A 0 n['I" PSI oS/» DATE/ -30-'`1 <br />❑ APPROVED <br />APPROVED WITH CONDITION(S) <br />❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />' <br />r , <br />DATE 2 /- X <br />PLAN REVIEWER'S NAME <br />ANY DEVIATIONS FROM TH15 APPLICATION M <br />ST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />1> l t & �t n <br />17, <br />11 r ' roti <br />NQ c f7 <br />1 <br />LM Z7 Wti (Mt VIJtU IWI B/BB) rage 4 <br />