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SAN JC )UIN COUNTY PUBLIC HEALTH ' RVICES <br />ENVIRONMENTAL HEALTH DIVISIO'16 <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTfTEMPORARY 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 />L94REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />FACILITY INFORMATION <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />EPA SITE # Opy 22:?j oµl I PROJECT CONTACT 'I212,cA. tj A C La <br />PHONE# 209 - 83 - <br />FACILITY NAME L Aj <br />CONTRACTOR ADDRESS (�..(- <br />PHONE # 20 - S - 3 <br />ADDRESS S/ I II- S'TX6(6 -r <br />t.pi) S <br />WORKER COMP# F(� <br />CROSS STREET <br />FIRE DISTRICT Lli <br />� A Tf <br />PERMIT# caagzeifno <br />OWNER OPERATOR .Sp <br />/✓LtLA6.J( <br />PHONE# 209-638-iOS <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />CONTRACTOR NAME <br />PHONE # <br />4ClTr SZ�F— GI(o S <br />CONTRACTOR ADDRESS (�..(- <br />S-Tre, /l�JD CA LIC # <br />CLASS A C D <br />INSURERQ)/ L� <br />WORKER COMP# F(� <br />39- <br />FIRE DISTRICT Lli <br />� A Tf <br />PERMIT# caagzeifno <br />LABORATORY NAME A( <br />COUNTY -$3� 7AkQ.4A-) PHONE # <br />S i.. -Cq p <br />SAMPLING FIRM <br />CAL— PHONE R Z(i% -S7Z.- p%CrJ <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- 5-D" <br />CGSN� Gene, eLv �J <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 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' CO PENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: •1 CERTIFY I E ERR��ORMANCE QF E WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LA 0 CA FOkNIA- / I/ <br />TITLE &!�L L"b) DATE O t / 1 <br />❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE N " <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />l\Sr1 i - - Paa txC l &N <br />C� CA ( ll-) lirs f A1yH I r' 6F lel= PEc Tjcs�.J <br />s rl fzYiY1C1V&� `pi PIN T�wfn 0Iv,pt- i I`SpEcR <br />>'N <br />EH 23 046 (REVISED 10/19/98) Page 3 <br />