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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> '✓ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # �J � ,.� t '/: ' ,) PROJECT CONTACT & TELEPHONE # i v - - - <br /> F FACILITY NAME C,LT�. C: AC�L-"",kms: =l. � ��- -�'-`L «-M-,�—T-�� PHONE #Ze)2 <br /> A1 <br /> L CROSS STREET <br /> T OWNFL/OPERATOR , PHONE # <br /> Y _ - <br /> C CONTRACTOR NAME -! PHONE # r'i-'t/ <br /> N CONTRACTOR ADDRESS-',,, .<� ;. ,` - . CA LIC # (;-,... CLAS2S- <br /> K INSURER ;._, '' /�1/ �'!/ WORK.COMP.#` <br /> A _ <br /> C FIRE DISTRICT,- I la ' _ - PERMIT # <br /> -Y /- <br /> 0 LABORATORY NAME 1 i' i ' //i ii,.aj ,� ,--" PHONE <br /> SAMPLING FIRM �,:',i, -� ;�, 1'•„ '�( �C (' .l"( PHONE #< �'�� <br /> — 1111111IIIlllllllllllll�llllll ' /--- / � , <br /> TANK ID t1 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- _ <br /> P 111111111111111111111111111111 Ililllillillllllll�llllillllllll 1I1111111111111111111111111111111111111 Illllllllllllllllllll <br /> L APPROVED /APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE TACHM T WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> nIn1IIn1IIInnIIrrr r r I iffni ffffrFffffffnmfffffrrmTf <br /> rrrn <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 SER""' <br /> OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORT( FORWHICHTHIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE P RFORM E OF HE WORK FOR WHI CH. THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL ORNIAP <br /> c �J <br /> APPLICANT'S SIGNATURE: - TITLE c/ ! S' DATE ��� <br /> QA__/..L-- <br /> ondlfions <br /> EH 23 04 ( evised 4/26/94) Pa e <br />