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F/E�.) <br /> SAN JQ UIN COUNTY PUBLIC HEALTH S' '.VICES c-op <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYSFIjO)Tr�TPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br /> El REMOVAL (� 71 ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> i FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT 959 PHONE 3—Q.,30'Z- <br /> FACILITY NAME1_- <br /> ADDRESS L LpA40rD Gam' LO C/4 - <br /> 10 <br /> CROSS STREET LLUFF fl-f/C vE <br /> OWNER OPERATOR PHONE a <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME g L �' �/ PHONE i Zd �1�L-SZ/ <br /> CONTRACTOR ADDRESS Q KO COd v _ CA LI # 7 CLASS <br /> INSURER /it.b GO WORKER COMP'# lsv / <br /> FIRE DISTRICT Q PERMIT# <br /> LABORATORY NAME 4Cr-c11qb /NC . COUNTY &V115, <br /> V PHONE �I/6 7,57 O <br /> SAMPLING FIRM PHONE 707 — SSy3 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT 8 PAST) DATE INSTALLED <br /> 39- l i �31Ior to 000 / Fr v l98'O <br /> 39- 3-TAt3Yiv s_ ooj <br /> Di <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITP,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 FORT RICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LA" S 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' �j T <br /> APPLICANTS SIGNATURE <br /> TITLE�"�Fit // 4A I°'P' ATE/ " <br /> ❑ APPROVED WAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/Oft ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME �' G , �V�' DATE ��rr <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS:r <br /> crormnl4t ' N <br /> d ('��jp�lf �r <br /> 7D t<,4"1-' <br /> EH 23 046(REVISED 1 /19/98) Page 3 <br />