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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTREMPORARv CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TAN!',Sl EXPIRES 90 DAYS FROM THE APPROVAL GATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PgAMIT TYPE <br /> Ci REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA srTE eCAC 0229 PROJECT CONTACT PHONEM (qQq —8497Q <br /> FAC.LITY NAME JOe Omac i Property PHONE# <br /> ADDRESS J n 211 <br /> CROSS STRW, <br /> OWNER OPERATOR Joe Oma,vhi PHONE P <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Jim Th r e PHGN[ <br /> CONTRAC-OR ADDR:SS P.O. B 'I CA LICA CLASS <br /> INSURER Gen St ar/Golden E le WORKERCOMPA <br /> FIRE DISTR.CT e It Of St ;ckton PERMIT# <br /> LAOCRATORY'NAME An coL:Nr PHCNE# _ <br /> SA:'PLING I M FN N # <br /> TANK INFORMATION <br /> TANK!D# TANK SIZE TANK CONTENTS(PRESENT& PASS DATE INSTALLED <br /> 39 550 gal gasoline unknown <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WATH SAN JOAQUIN OOUNTY OROINANCES.V,4-E LAWS FEOIRAL LAWS..ANO 11(t;LEB AND <br /> ReiU.ATIONS OF SAN JOAQUIN :AUNT". PUBLIC HEALTH SERVICES. (h-AER OR UCENSEG AGENTS SIGNATURE CERTIFIES.THE FOLLOVANOI 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THEMRK FOR LMHICH THIS PERMIT"S!SSUIO.I SH:aL NOT EMPLOY ANY P:RSCN IN SUCH A MANNER AS <br /> 70 BECOME SUBJECT TO WORKER'S COMPENSATION VNJ9 0°CALIF NIA: CONTRACTOR'S HIRING OR SUSCONTRAGT1NQ SIQNATUFS CERTIFIES <br /> THE FCLLCWINO: 'I CERTIFY THAT IN E FORMA'P THE'r'VO FCR WHICH THIS PERMIT IS ISSUED I$HA.L EMPLOY PERSONS SUBJECT TO <br /> 749PKIR'S COMPENSATION LAWS 0 RNi <br /> APPLICANTS SIGNATURE LE ractor OAT=6/5/00 <br /> ❑ APPROVED APPROVED WITH CONDITIONS) Q DISAPPROVE) <br /> 71 <br /> 41,E (SEE CONDITIONS BP:0W ANGOR ON P.TTACHMEHTI // <br /> NPLAN REVIEWER'S NAME DATE- <br /> ANY CEVIATIONS FROM THIS AP°LICATICN MUST Be SUS ITTED TO EMD FOR APPROVAL PRIOR TO COMMENCING WORK. VIII <br /> CONDITIONS: <br /> I � 8 <br /> EH'e3 046(REVISED 08!13!99; P;y.3 <br />