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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH 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-T-YPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE (CLOSURE IN P hV, <br /> EPA SITE # f4 J PR=OJECT & TELEPHONE <br /> F FACILITY NAME PHONE # 0 <br /> A <br /> C ADDRESS {` � , <br /> I <br /> L CROSS STREET c <br /> I PHONE <br /> T OWNER/OPERATOR <br /> Y kx- C t d <br /> C CONTRACTOR NAME PHONE # � <br /> fJ�-Q-L � <br /> © �t CA LIC # 3 CLASS <br /> N CONTRACTOR ADDRESS �Glcz <br /> - � <br /> T WORK.COMP.# N N�, yZZa�]-db <br /> R INSURER - <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T I �5 COUNTY- PHONE 047- Z <br /> 0 LABORATORY NAME `, <br /> R PHONE <br /> SAMPLING FIR h1 Cs r".ti�� an <br /> 1111111111111111 111111111111TANK SIZE CHEMICALS STORED CURRENTLY REV1 DATE UST INSTALLED <br /> _� TANK ID # " <br /> 39 � j C v <br /> T 34- o E 7 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> llll!llllllll11111111111111111 1111111111111111111111111111111t illllll{111f{11111111111111111111111111 llllllllil1111111!! <br /> PDISAPPROVED <br /> L APPROVED APPROVED WITH CONDITION(S) <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N 7_ <br /> DATE <br /> PLAN REVIEWER'S NAME__ � � <br /> 11111111111111(IIII!lllll!!l11111111111111111111111i11111111i11lllllill lllillllilll{lltt111111111111111111111111111111111111 l <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 ISSUER, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> "IBCERTIFY THHATEINSTHEMPERFORMANCEAOF THEWORKFORAWHICHOTHISCPERMITHIRING <br /> ISSUED, I SUBCONTRACTING <br /> EMPLOYSIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTHE <br /> OWING: <br /> WORKER'S <br /> COMPENSATION LAWS OF C LIFORNIA." <br /> TITLE DATE -.l <br /> APPLICANT'S SIGNATURE: <br /> CONDITION(S): <br /> 3 .S <br /> Qj cam `' �Ig 17 cPub -aka <br /> �3 � <br /> kE N'vs `�TAL H► . <br /> EH 23 046 (Revised 9/11/96) <br /> �J Page 3 <br />