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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITFMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE 7K(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE,REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EAE#CA L 1208037 PROJECT CONTACT C IIZIS PAt4h LTESCU PHONE# - 2 - SSti x 370 <br /> FACILITY NAME BEST CAL.kVORNIA QAS I L, cI 172. PHONE# <br /> ADDRESS !- PACI;rtCAVE STDG YJ ICA Q5207 <br /> CROSS STREET P_I N/A 2^ <br /> OWNER$P 9R $GST CAL-lf�bbl; A. PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 4 - PHONE# <br /> CONTRACTOR ADDRESS w r-t CA LIC# CLASS -IiA14Z <br /> INSURER WORKER CONfP# 1 `I <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY r PHONE#(-71 <br /> G� <br /> SAMPLING FIRM PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 1- 79- 5YO (Q 12-11660 We SeAt-,IE KM PAsf : Lt6rU at <br /> 39-06-0 c_(? 12 000 E Aii o <br /> 39-13S'0G 12 00 ID Ep! ffof o1 Als <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBtT TOW KE R'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWNG', C TIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WD R' CO ENSATION LAWS OF CA FORNIA.' <br /> APPLICANT'S SIGNATURE TITLE UreS I DATE ' <br /> ❑ APPROVED XAPPROVED WITH CONDITION(S) D DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE �13'6 <br /> ANY DEVIATIONS F OM THIS APPLLCATION MUST BE SUBMITTED TO EHD FOR APPROVAL.PRIOR TO COMMENCING WORK, <br /> CONDITIONS: <br /> EH 23 046 (Revised 11/21/06) 3 <br />