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..F <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> NCES <br /> STORAGE <br /> PERMT FOR PER90 DAIYSORARY CLOSURE OR A0.4NDONMENT IN Fu-�CS OF F FROM THE APPROVAL CATE. 00 NOT INR E IN ANY SHADED AREARGROUNDS NDICATE P A�+IITARDOIjS ATYPE <br /> STORAGE 7ANK:,SI EXPIRES <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> SPA SITEk PROJECTCONTACT I I PHONEN 982=4675 S ri JOa Ulri OOUnt MO UltO r I PHONE. — <br /> ADORFSS 2O B <br /> CRCS�S'REE7 PHONE# <br /> OYMER OPERP70R <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Jim Th r e Oil , PHONE* <br /> UA <br /> CONTRAO-OR ADDRESS P.O. B 57 CA LIC# CLASS <br /> INSURER Golden EaglD / Ro al WORKER COMPO 71 Q7 <br /> FiREDIS'RICT The City Of Stockton PERMIT# <br /> COUNT" PHCNE# — <br /> LABORATORY'NAME oAn <br /> QRRR <br /> SAMPLING FI M FNONE 0 _ <br /> TANK INFORMATION <br /> -ANK ID g YANK SIZE TANK CONTENTS(PRESENT& PASS I DATE INSTALLED <br /> 730� <br /> p —0 <br /> Q 6000 al Neutral Oil <br /> Ig 0 (' <br /> � 7500 gal Neutral Oil <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PIRFORM ALL VbRK:N ACCORDANCE."'ATH SAN JOAQUIN COUNTYCROINANCES,STATE UkWS FEDERAL IAVVS,.AND RIiLES AND <br /> REvU�1TIOMS OF SAN JOAQUIN COUNT`.'PUBLIC HEALTH SERVICES. OVMER OR LICENSED AGENTS SIGNATURE CERTIFIES THE °•]DOWING: 'I <br /> CERTIFY THAT IN THE PEP.FOIWANCE DF-HE WORK FOR PAIICM THIS PERMIT�S'SSUID.I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO EEDO:'A!SUBJECY TO WORKER'S CoMoSNSA7104 LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CUMFIES <br /> ..Op CRL5^OMPENSATION LAWSTOP I E F0�A.MANCE OF TME W F iNNICI'THIS PErL111715153UE0.I SHA.L EMPLOY PGPSONa SUBJECT T.J <br /> Contractor 10/19/0 <br /> APPLCANTS SiGNA?URE <br /> LE DAT= <br /> ❑ APFROVED PPROVED WITH CONDiTION(S) Q DISAPPROVED <br /> (SEE COKOMONS SE,CVJ ANrICR ON A.TTACMMENT <br /> i <br /> I1I DATE <br /> N PLAN REVIEWER'S NAME1 <br /> ANY DEVIATIONS FROM THIS AF°LIGATION MUST 6E SUEMITTEO TO NHD FOR APPROVAL PRI R TO C NE LING I, <br /> CONDITIONS: <br /> t <br /> EH a7 7a6(REVISED 08113/99; F`9a' <br />