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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPCRARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGRCUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYSFROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> EPA SITE # C�' L DQU PROJECT CONTACT i TELEPHONEO_p ioL ('r) <br /> S NO <br /> ! F FACILITY NNE ( AlQ-rvloll' kc KI PHONE # cJ/V gV Z 1a 2-'A _ ( 11 <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR '' II PHONE # <br /> T U- <br /> C CONTRACTOR 4AME _f ^� n PHONE X <br /> 0 � S <br /> N CONTRACTOR ADDRESS CA LIC # CLASS AYI- <br /> r <br /> - <br /> R INSURER WORK.CCMP.# <br /> A <br /> CFIRE DISTRICT lel PERMIT # <br /> T <br /> 0 LABORATORY NAME PHONE # 5 <br /> R <br /> SAMPLING FIRM v-\ PHONE # -7c)-� <br /> Illlllll1111111111 161111 <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- -* I1 -05 a 5n <br /> T 39- gm I13sr-06 z <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 111111111111111111111111111111111111111111111111111111111111i1111111111111111111111111111111111111111111111111111111111111 <br /> L X APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A HMENT WITH CONDITIONS) ? <br /> N PLAN REVIEWERS NAME DATE 3- Y <br /> 1111!111111111111111111111111111111111111111 11111111111111111111111111111111111111l1111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL LARK 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: -1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 FOLLCWING: <br /> °I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCMPENSATION LAWS OF CALIFORNIA." � cM��� is <br /> -_� lh'5-f AO <br /> : 1�,)a I�_ D (� rt/ fl a TITLE �{ DATE <br /> APPLICANT'S SIGNATURE . <br /> L Z3 046 (Rev 2/8/91) ft Page 3 <br />