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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONk,IENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />'HIS PERN17 FOR PERMANEN—?TEMFOFAR� CLOSURE OR ASANDONMENT IN PLACE OF UNCERGROUND HAZ4RDCl1S SUBSTANCES <br />STORAGE TANW,SI V PIRES SO MAYS FROM THE APPROVAL OATS, OC NOT'vvRCTE IN ANY SHADSO AREAS, INDICATE PcRMR TYFE <br />REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFGRMATIC'N <br />c TANK CCN7E475 (PRESEN7.4 PAS" , DATE INSTALLED <br />KID* I TANK SIZ <br />39- 7 500 a <br />39- <br />39- <br />39- <br />39- <br />39- <br />APPLICANT <br />9- <br />39- <br />3939- <br />39. <br />APPLICANT LIUST PLRFORLI ALL NARK ;4 ACCOROANCE'v)AN SAN JOAQUIN COUNTY GF.OINANCES• 5 •ATE LAM FECLRAL LAWS. .4NC 4L.1ES ANO <br />RE iUI.1T�ONS OF EAN JOAOUIN CCUNT' PUBLIC HEALTH SERVICES. ONMER OR UCENSEC. AGENTS SIGNAT!JRE CERTFIE3'HE =OL.CV+INC; 'I <br />CEP7irY T HAT IN THE PEPFCRAMK:E 7� SHE WO rCR'dAiICH TFI$ PLRMIT S' ULD I SHALL NOT'V..PLOv ANY P_RSCN IN SUCH A IMwFMF ES <br />TO EECC'rtL SUBJECT TO WORKE21'S COMoeN•J LAV45 OF CALIFOR • OR'3 HIRING Of. 5USCONTRAGTIN0 SIGNATUF.E C>ipYIFIES <br />..a, S_ Rrc pF T•IE//�'�ORK ?' ^ THIS PEn7diT IS ISSUED. I SHA -L EMPL0" PLPSONS SUS+E:T TO <br />—�Sp=MINO 'I CER-riulY THAT IN <br />OPxLR'$ COMPLN$ATCN LAWS OF <br />, 2 � DAT° <br />AMPL,CANTS S;W <br />Cl APPROVED 0 APPROVED WITH CONDiTION(S) G D <br />(SEE COKCI-ICNS B?.CW ANC/CR OH A.TTACHfiiLNT) <br />DATE <br />PLAN RE41@NER'S NAME <br />ANY CSVIA-.ONS FROM THIS AjOLICA7ICN ]lUSI' 3�SLaMITTEO TO ON'D <br />CONDITIONS, FOR APPROVAL PRIOR TO COMMENCING WORK. <br />