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SAN JUIN COUNTY PUBLIC HEALTH VICES <br />NVIRONMENTAL HEALTH DIVISIO <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />6 <br />FACILITY INFORMATION <br />EPA SITE # ( <br />PROJECT CONTACT — 1/7, - q s -_C•.c i PHONE# <br />FACILITY NAME <br />er _ S PHONE # <br />ADDRESS <br />-(;. <br />CROSS STREET <br />r <br />OWNER OPERATOR <br />-- L 0)1/1 e C.G. PHONE* - 1 C <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />TANK SIZE TANK CQNTENTS RESENTS PAST) DATE INSTALLED <br />CONTRACTOR NAME <br />-[' ,S 7 r - tri <br />PHONE # "1 <br />CONTRACTOR ADDRESS <br />Q E, h CA LIC # <br />Z� CLASS gD <br />INSURER <br />t i• , WORKER COMP# <br />CONDITIONS: <br />FIRE DISTRICT <br />/ PERMIT# <br />LABORATORY NAME <br />COUNTY I y- <br />PHONE # <br />SAMPLING FIRM <br />- %L�� PHONE d A <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CQNTENTS RESENTS PAST) DATE INSTALLED <br />39- <br />39- I <br />^tirll C ,1dAh , <br />- <br />39 61 <br />- •�L <br />39- <br />r `� <br />39- <br />CONDITIONS: <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: "I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFQfNI//, <br />i iI n <br />APPLICANTS SIGNATURE c <br />�Y - TITLE C C-- �, �I/�'�CC i DATE <br />�j <br />CONDITIONS BE•AND/OR -N ATTACHMENT) <br />PLAN REVIEWER'S NAME //.�' <br />- •�L <br />• it <br />/�.I <br />ANY • • • • I] • TO EHD FOR APPROVAL PRIORTO COMMENCING WORK. <br />CONDITIONS: <br />