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Fuc cap <br /> PAYMENT D� � <br /> RECEIVED Q <br /> AN d 8 1993 AN 0 8 1993 <br /> SAN JOPupLIC AQL+ffV WON'T', <br /> ENVIRONMENTAL HALTH DfCE-SIUIS ON ENVIRONMENTAL HEALTH DIVISION �NVfRC7N <br /> �'E12�1lTlSERVICES 1_TN <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR A8ANDCNMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DC NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> L REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE C�4r�.�, PROJECT CONTACT & TELEPHCNE # jLT 7;� a� <br /> 9 5zy� 96s3 <br /> F FACILITY NAME T,-Pu�K Z&4.<I�(/G �p,Qy, PHONE # Zd9 <br /> A <br /> c aDOREss /�3� S' ' �7oroc/ Src Srac,eTvr�< Com. 95'zo� <br /> I <br /> L CROSS STREET &#4161 Q�/IiE <br /> I !/ <br /> T OWNER/OPERATOR PHONE # <br /> Y - /r STip-lam f GGK L E STN + oRP. Z-Al ?9 4 Love,? <br /> t39 ACTOR NAME SSMCo PHONE # Zp9 J6z,/ "653 <br /> N <br /> ACTOR ADDRESS / W+ fj/QTG� ,�d / D� T� CA LIC # zl1 9S�� CLASS T� �!,�y/—psrd <br /> ER -7`Od��r n asr.o��� d�'WORK.CChiP.# 7 ��D[STRICT �fTGf OF ` �� ¢C 82- 5 PERMIT #7ATORY NAME �EQ✓ff(//I�Lr"/ LPHONE # J!IMG FIRM v�() /✓r9CG/T/ PHONE # '�()IIIII1TTANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATA ST INSTALLED <br /> 2 eeoN 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P I1I111i11111 1111 111 I11MVE <br /> 11111111L P OVEDND[TION(S) DISAPPROVED. <br /> A (SEE CONDITIONS)N PLAN REVIEWERS NAMEDATE 1 f <br /> 11111J1IIIJIIIIIIJJJ DATE I <br /> APPLICANT MUST PERFORM ALL 'FORK IN ACCORDANCE WITH SAN "QUIN 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 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WCRKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTORS HIRING CR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWENG: <br /> "I CERTIFY THAT IN THE PERFCRMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE FJeT/m'*TO 12-' DATE !�—9 <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />