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SAN JOAO' I COUNTY PUBLIC HEALTH SER' ;ES <br /> ENV'rRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> > l REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#GRD BZ3+7°`ID PROJECTCONTACT IN 5f PHONE# 7,0 • L�' G �i <br /> FACILITY NAME I VV 5Tottr 9!p- jq'7C5 PHONE#24M • I Uf (I <br /> ADDRESS 1 �(i/I1JI% -'FD!4 C4 01524O <br /> CROSS STREET UffMt <br /> OWNER OPERATO L- at' PHONE# ZO B.Stt 61 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME S NGtNC(/rrNEtPHONE#,3 •sli llsJ(03 <br /> CONTRACTOR ADDRESS,3 3 I DYi 1/'(6 k* CA LIC# 12,&3L570 CLASS <br /> INSURER$.L. E14I"N MIEI`t WORKER COMP# Z • 00 <br /> FIRE DISTRICT u*'f 01' PERMIT# <br /> LABORATORY NAME ANAnflk I COUNTY PHONE#SaC) • Z247<5 O <br /> SAMPLING FIRM (r& rjI PHONE # 76 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- OIL I`� <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: -1 <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: 'I 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 /> APPLICANT'S SIGNATURE I TITLE� i9t4r 1 0fZ—"#'A-, <br /> �14AUZ-DATE I 00 <br /> ❑ APPROVED ID APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> j (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> i <br /> PLAN REVIEWER'S NAME L - i DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> P - <br /> y <br /> EH 23 046(REVISED 08/13/99) Page 3 <br />