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SAN PAQUIN COUNTY PUBLIC HEALTH RVICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT-COR PERMANENTrMMP©RARYCLOSURE OR ABANDONMENT IN PLACE OP UNDERGROUNO HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIRES 90 DAYS FROM i HE APPROVAL C)ATE. CO NOT WR17E)N ANY SHADED AREAS_ INOICATE PERMITT`PPE- <br /> t2 REMOVAL Cl TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE °RC?JIwCT GO+�TACT GC3t`J� PHONE# 3'-3 <br /> FACILITY NAME z2i eG`I 7;, 570,C,�'�aJLJ PHONE* <br /> ADDRESS 2- ;v. 1 1 0-v <br /> CROSS <br /> 7- <br /> CROSS STREET <br /> OWNER OPERATOR <br /> PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRAC"OR NAME Jim - Orpe 011, Inc. PHONE# 209 35 - Y7 <br /> CONTRAC T OR ADQRESs cA LIc#, �56 5 c;LAss A B .HAZ <br /> INSuRERAmerican Interna.t' I Spec-Liz .5 WORKERGOMP# State 'Puma 1671173-02 <br /> FIREDISTRICT if / = .S �9C�., PERMIT# 1 oil A ru.vLl <br /> LABORATORY NAM ICU Z , �� R f —PNgg � <br /> SAMPLING FIRM 44, <br /> TANK INFORMATION <br /> TANK ID# I TANK SIZE TANK CONTI=NTS PRESENT& PAS DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- - ---- A <br /> 39- <br /> 39- <br /> APPILCANT <br /> 9-39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPIICANT MUST PERFORM ALL WORK IN ACCORDANCE WFrH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS,AND RULES AND <br /> REGUL.4TIQNS CF SAN JOAQUIN COUNTY PU51j(;HEALTH SERVICES. OWNER OR LICENSED AGENT'S SiGNA,JRE CERTFIES THE CL LOWING: 't <br /> CEATIFY'f'J.AT IN THE PERFORMANCE OF:—,t-IE WORK FOR WHICH THIS PERMIT 1S ISSUED,I$HALL NOT EMPLOY ANY PCrSSQN IN SUCH A MANNER AS <br /> TO BECC]ME SUBJECT TO WORKER'S COMPENSATICN LAWS OF CALIFORNIA" CONTRACTORS HIRING OR SUBCONTRAC'TNG SIGNATUAE CERTIFIES <br /> THE=OLLOWING: 't CERTIF`!THAT IN T ORMANCE QF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL E?VPL,CY PERSONS SUBJECT TO <br /> WORKER'S COMPENGA'MON LAWS A FQR <br /> APPLICANTSSIONATIJRE TITLE COT traCtOr DATE-34Vff <br /> ❑ APPROVED ❑I APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDCCIONS BELLOW AND/OR ON ATTACHMENT) <br /> PLAN RSVIE7WER'S;SAME DATE_ <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST IaE SUBMITTED TO EMD FOR APPROVAL PRIOR TO COMM£NGTNG WORK. <br /> CONDITIONS: <br /> EH 23 048,RF-VISED 08113199) Page 3 <br /> Td WdS0:80 tr®Bz 10 'adH TS9T-89Z 60E : 'ON Xaa 'ONI `710 ddH0H1 WIT' WOdd <br />