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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAL'T'H DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE TANCE <br /> PERMIT FO <br /> DAYSP FROM THE/APPROVALYDATE. DO NOTE OR WRITEIN IN PLACE OF UNDERGROUND ANY SHADED AREAS. INDICATEAFERMIUTYPE SSTORAGE TANK <br /> BELOW: <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE N PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # S�}-t �Str� '7--7 --199 <br /> cool 3') <br /> F FACILITY NAME r ✓ r PHONE # to� -Z <br /> A33 <br /> C ADDRESS XjpQ W I { U M qrJ <br /> I \ <br /> L CROSS STREET C AI( OCT WD <br /> I PHONE # <br /> T OWNER/OPERATOR <br /> Y ASP —✓e I S s e y 1G, <br /> C CONTRACTOR NAME G PHONE _ yy(P_-199c, <br /> OQ CA LIC #`f-17 CLASS <br /> N CONTRACTOR AD(�RESS 2.,,q,> -? Jy pp <br /> T ,�lo Q, <br /> R INSURER9(1Gu�, rnC�o .L,)._ i <br /> WORK.COMP.#TT IX�Y �-Q /�'� 67J g6 ' 6 <br /> A PERMIT # <br /> C FIRE DISTRICT .Rq Z:,.t=x M u a <br /> T 1PHONE # <br /> 0 LABORATORY NAME ,,411 Q VI/off C NTY SD— — g3`6 <br /> R (� �� PHONE # <br /> SAMPLING FIRM V'�L -.r,)CL[ <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIII <br /> TANK ID # TA <br /> WK S E CHEMICALS STORE CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- b 0-2- <br /> T <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39-- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION($) DISAPPROVED <br /> A EE CON ITIONS BELOW AND/OR ON ATTACHMENT) <br /> NDATE <br /> PLAN REVIEWER'S NAM <br /> 93 Q19.6 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCO ANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI S. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1-1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH HIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SIB CERTIFY THATERINSTHEE PERFORMANCEAQF THE WOORKOFORAWHICHOTHIISCPERMITH ISNG OR ISSUED, I ONTATING SHALLCEMPLOYIGNATURE PERSONS SUBJECTETOTHE WING: <br /> COMPENSATIOF WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.-' Q <br /> �� TITLE _,(P D DATE 11 u <br /> APPLICANT'S SIGNATURE �^� <br /> CONDITION(S): II_ fif7- E'A)G' <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />