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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <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 # PROJECT CONTACT & TELEPHONE # u�IL-LRAM J• MAVULUCH <br /> caL 000 oo a 8 5� Cq I 346 - 505-7 <br /> F FACILITY NAME AK(-o PHONE # (20q) 334- No-7e <br /> A <br /> C ADDRESS BOO EA5T {CE TT UG MAK] LAQt-� <br /> I <br /> L CROSS STREET H I G H wAy C(q <br /> I <br /> IOWNER/OPERATOR PHONE # cIo 5AILGHAUSEQ Et.]Gt�S <br /> Y AT�PItJT1C. R1�-4E1=1�Lt� coMPPrt�Y C91(o) 3416- 3057 <br /> C CONTRACTOR NAME G C)U V(i Q W C-5T PHONE # A S) 6034- 1 gq0 <br /> 0 <br /> N CONTRACTOR ADDRESS J�,r2,ENTW ppq r CA CA LIC # 432„ 103 CLASS A <br /> T <br /> R INSURER N/A WORK.COMP.# (� <br /> A <br /> C FIRE DISTRICT LQCJL 1=1121✓ VFPAV-TK NT PERMIT # r <br /> pc, r41 <br /> T <br /> 0 LABORATORY NAME APPLIeP ANALYTILAL� ENVIRON, l-AI!,s PHONE # (910 4r-,2 713(0 <br /> R <br /> SAMPLING FIRM APi�L1�D CzEOO✓�/5T�(v�S PHONE # Cql(o) 462- 2901 <br /> III II1111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- % 31/6 1 10 o00 GAL. 111$ <br /> T 39-� �' -' 2 6,000 <br /> A 39-��y G - 000 11 ti tt <br /> N 39- - 000- <br /> K 39- 13 <br /> 39- <br /> 39- <br /> III it 111 11 111 11 11 111 11 111 11 111 11111111111111111111111111111111 II III1111111111111111111111111111111111111111111111111111111 <br /> P <br /> L _ APPROVED �APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / c /°(SEE /ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMEa�[+(ilf ` DATE <br /> III1111111111111111111III11111111111111f11111111111111111111111111111IIIIIIIilllllllllll Illllllllllillllllllll IIIIIIIIII IIIII <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." <br /> APPLICANT'S SIGNATURE: TITLE AwE1UT fU� AK-LD DATE I I-1`R 1 <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />