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f <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE I M IIT <br /> I <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE k 011- 00c)3j '' PROJECT CONTACT & TELEPHONE X �61A ,'(,1,t C I 7(r'I•�i7J3 <br /> j F FACILITY NAME I�ICLL� b0 [� PRONE x�y�G) �L)Z <br /> A 5-+-- <br /> � �7 <br /> C ADDRESS '� . T (r.( ()-vl 6f S 77(00 <br /> l <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE �G ` ZJ�' l 4 '�,Z <br /> Y �lu.4,t� i-vods 4/ J l / <br /> C CONTRACTOR NAME SEMS I PHONE Al 209 524-9653 <br /> DC 1 D40 B A HAZ <br /> N CONTRACTOR ADDRESS 1217 S. 7th $t, Modesto, CA 95351 GA LIG x 449864 cuss <br /> R INSURER Insurance Company WORK.COMP.X 11 <br /> A <br /> C FIRE DISTRICT IzI eft4 I PERMIT X j <br /> 1 ASB C57 <br /> T <br /> 0 LABORATORY HANE GeOANdlVtlCal Lab COUNTY Stanlslaus PHONE X (209) 572-0900 <br /> R SAMPLING FIRM GeoAnalytical Lab PHONE X (209) 572-0900 <br /> III IIIIIIIIIIIIIIIIIIII[III III <br /> TANK ID XTANK SKE / CH ICALS STORED CURRENTLY/PREVIOUSLY OA U T INSTALLED <br /> 39- - f! 10 &ey (p0_L /JfLSCl <br /> T 39- <br /> A 39- <br /> 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIIIIIIIIIIIIillll IIIIIIIiII IIIIIIIIIIIIIIIIIII111 IIIIIIIII 1111111 IIIIII1111111111 IIIIIIIII 11111111111111111 I Ilill <br /> P <br /> L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <br /> I I I I I I I I I I I I I1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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 WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:', <br /> "I CERTIFY THAT IN THE PERFORMA E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI . <br /> r <br /> f APPLICANT'S SIGNATURE: TITLE DATE <br /> I CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> �o4Ar- ca roc , ` %�S.^6'S r^a GAS EI Dr��' Y'vEG, <br /> A,-r-r 6 if r^•Earccy rtev� 44V` c.-4teq-r- 1Avtee, lee C,sz-vg' -I- J <br /> I EH 23 046 (Revised 9/11/96) Page 3 <br />