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0 0 <br /> 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 TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # LOOI ^ PROJECT CONTACT & TELEPHONE # S')"t� ES 7e7 -799 <br /> F FACILITY NAME r ^� PHONE # Zo 5 _Z <br /> A h <br /> ADDRESS <br /> I ay AveSc <br /> L CROSS STREET S. AIS Wa <br /> I <br /> T OWNER/OPERATOR _ PHONE # <br /> Y g —re 1 s Loc- -576 <br /> C CONTRACTOR NAMEc- PHONE # 1�1 _ yy6_-199co <br /> 0 <br /> N CONTRACTOR ADDRESSQ * (10 CA LIC #`f-�•-� CLASS <br /> R INSURER L.IC -&I\d'0 OU e4LQ WORK.CONP.# <br /> C FIRE DISTRICT �� M a PERMIT # <br /> T 1 <br /> 0 LABORATORY NAME Hol�J, E <br /> R 11A�Q. COUNTY S J PHONE # �'D_ S• _ vs <br /> SAMPLING FIRM `(JAL_ PHONE # -7D'7 yy(,_795(n <br /> TANK ID # TANK SIZE CHEMICALS STOREp CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- I0,000 cn LJea -DiestI �1b� <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <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 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 5p p <br /> APPLICANT'S SIGNATURE TITLE llo'—yj D DATE II 1 O <br /> CONDITION(S); <br /> • <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />