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SAN JO,..„UIN COUNTY PUBLIC HEALTH S..VICES <br />ENVIRONMENTAL HEALTH DIVISION <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />CONTRACTOR INFORMATION <br />FACILITY INFORMATION <br />EPA SITE # <br />PROJECT CONTACT 1Pt)rW17jPHONE# - <br />FACILITY NAME C IT <br />p s AC c 4�-7K QUICA /Ctc PHONE - l- it $ <br />ADDRESS <br />J CLASS <br />CROSS STREET <br />ll*ORKER COMP# <br />OWNER OPERATOR <br />PHONE # <br />CONTRACTOR INFORMATION <br />TANK ID # <br />CONTRACTOR NAME (LL HI'T Nj14 N <br />TA 5E2VIC LAIC . <br />PHONE # C _ 7 <br />CONTRACTOR ADDRESS iq <br />�-OACA LIC # <br />J CLASS <br />INSURER q4n4o Fij.yl <br />ll*ORKER COMP# <br />FIREDISTRICT C4 01C r f_c . <br />LABORATORY NAME v� <br />SAMPLING FIRM -rMjf: <br />,)p'Pl ' <br />PERMIT III <br />UNTY <br />PHONE <br />PHqONE #" -09 <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONT,/ENTS (PRESENT 8 PAST) DATE INSTALLED <br />39- <br />39- <br />t <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 SIGNATURE CERTIFIES <br />THE FOLLOWING: '1 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 <br />TITLE / /`e S DATE 3 - f%p y <br />❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME A//�� (n - */4 ",C DATE 0 U <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (REVISED 10/19/98) Page 3 <br />EH 23 046 (REVISED 10/19/98) Page 3 <br />