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VAX,- Et YIRONMENTAL HEALTH DEPARTMEI <br /> SAN JOAQUIN COUNTY j <br /> ,�9ViK NM , 'O-ICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUSSUB TANCEE <br /> II STORAGE TANK(S)EXPIRES IBD DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADEDAREAS. INDICATE PERMIT TYPE <br /> ILREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> I; r.A-DDlR-E-- <br /> CROSSSTREEj <br /> PROJECT CONTACT G �N O WE T <br /> Ij C/IL71P?Nl ok •r�c oc� S a w PHONE# <br /> )))I c /' 1'a • { Na• PHONE* N <br /> yyyp.' 4OR 4C <br /> PHONE# —GY7� <br /> CONTRACTOR INFORMATION <br /> J CONTRACTOR NAME r '�eq 11 PHONE# ,,? / <br /> CONTRACTOR ADDRESS (>� • / /V• O CA LIC# G O CLASS <br /> INSURER U = WORKER COMP# U,ft ,� .3 8 c <br /> FIREDISTRICT c /iLT /1(A i/Y um PERMIT# /Vq <br /> LAMPLIN FIRM mE SlE7 L / TD / f COUNTY .E X71 PHONE# O a .�70,r' <br /> SAMPLING FIRM e t O ORDOY/% PHONE# <br /> r <br /> TANK INFORMATION <br /> TANK[ # TANK SIZE TANK CONTENTS RESENT AND PAS <br /> 39-0 f1 3000- G / DATEINSTALLED <br /> 39- 06 3 co lsE - C <br /> 39- 0520%4 3 tc + fitL !,rl r W„ a/c- <br /> 39- <br /> 39- <br /> ic39-39- d 20 <br /> 139- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.FEREFF�MT..RNy14LWS.�,p1NO RU{{ES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OWNER OR LICENSED AGENTS SIONRRlRS7NER}IHES THE <br /> FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WMOCH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANYPERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO VARKER'S COMPENSATION LAWS OF CALIFORNIA' CON'rCTOpS L) <br /> SIGNATURE CFRT TIES THE FOLLOWING: 'I CERTIFY THAT PERFORMANCE OF THE WORK FOR WHLCR}{}IS�PE L9J <br /> 26M <br /> (L, <br /> EMPLOY PERSONS SUBJECT TO WORKER'SC LA OFCALIFORNIA' <br /> APPUCANT'SSIGNATURE c <br /> TITLE; /NCc/o/I t_ DATE, <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> n II,^�(SEE CONDI NS BELOWANDIOR ON ATTACHMENT) 7 <br /> PLAN REVIEWER'S NAME_:0 V\Q. �arti�-o OATE�1 1�_/5 <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> &e_ <br /> CONDITION : <br /> Q�laccn n�rnhrovaA t � Px Qfiorf I Iu 2015 <br /> EH 23 046 (Revised 07/17/14) 3 <br />