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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 SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE�AAPPPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> CON VAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # -7 PROJECT CONTACT 8 TELEPHONE # 009 <br /> F FACILITY NAMEHONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> PHONE # <br /> Y OWNE PER TO '51-0 -60 <br /> O O <br /> CCONTRACTOR NAME 6 PHONE #AV <br /> 0 <br /> N CONTRACTOR ADDRES LA LIC # �� CLASS <br /> T y <br /> R INSURER08Y WORK.COMP. <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> LABORATORY NAME /��/ VAe <br /> d ` PHONE # o <br /> SAMPLING FIRM Cri'T/4 PHONE #L76 �QC� <br /> TANK ID # �� nTANK SIZE CHEMICALS STORED WRREJITLY/PREVIOUSLY DATE�ST �STALLED <br /> 39- —` ��� H <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( EE AT H ENS WIT TH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> — 111111111111111 11 <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: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHIC HTM S PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION L F ;CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PE FORM CEFOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI RN �_ <br /> 74APPLICANT'S SIGNATURE: TITLE DATE _ <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />