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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAL'T'H DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ,,)L REMOVAL TEMPORARY CLOSURE __ CLOSURE IN PLACE <br /> EPA SITE # Co O CIO, i- PROJECT CONTACT & TELEPHONE # y o9 <br /> l Dau <br /> F FACILITY NAME - <br /> A � c N E (o.' PHONE # <br /> Z55 <br /> ADDRESS 0, LO�I.i <br /> L CROSS STREET C <br /> I <br /> T OWNER/OPERATOR ATTouAA c? 0 PHONE # <br /> Y SSA a�iTv - Co 30(01 Q - t, 818 - <br /> C CONTRACTOR NAME " <br /> 0 Q <br /> OL PHONE # <br /> N CONTRACTOR ADDRESS L n T FD CA LIC # <br /> T po CLASS <br /> R INSURER <br /> A S��-F rNi. le 5.�. (a.J WORK.COMP.#SEZt- <br /> C FIRE DISTRICT c <br /> T j PERMIT # <br /> RLABORATORY NAME SP4e_gEn- COUNTY � # <br /> rr 'I h6-33Z_ <br /> SAMPLING FIRM `Yh N{N`En1F, Cenp. g8`if IIIIIIIIIII III[ If I F. Crrpa .% 1+ci ..y 7S4yo PHONE #716-7Z.3 -7(,4T <br /> TANK ID # TANK SIZE CHEMICALS <br /> 39- -3 6- <br /> STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- 1 1 Z(t)OO C]dSDL i NF U� <br /> A 39- _ _. 21 non <br /> N 39- � 11 nao <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A <br /> N (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME '��/Z- /� <br /> DATE <br /> III If I I���������������������������������������������������������������������������������������������������������������������� <br /> APPLICANT MUST PERFORM ALL WORK 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: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL 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 FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: `F--�— TITLE (zo/4L**4 ATE <br /> DduK Ic . �DH�t.O <br /> CONDITION(S): <br /> EH 23 046 (Revised 9/11/96) Paye 3 <br /> i <br />