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SAN J04,QUIN COUNTY PUBLIC HEALTH SERVICES <br />NVIRONMENTAL HEALTH DIVIS I <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />APPLICANT <br />FACILITY INFORMATION <br />EPA SITE # <br />rya PROJECT CONTACT � lltb777 PHONE# 679-1jy1j <br />FACILITY NAME C <br />LCIC0 PHONE #, O p J`2 7 7 <br />ADDRESS ) 7-7 <br />J2son S <br />CROSS STREET jjLk2 <br />PERMIT # <br />OWNER OPERATOR <br />_ <br />- I y 1 - y05 <br />� C ,%S / PHONE #(-)I <br />TANK INFORMATION <br />APPLICANT <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME —% <br />PHONE # <br />CONTRACTOR ADDRESS <br />CA LIC # CLASS <br />INSURER <br />WORKER COMP# <br />FIRE DISTRICT ', <br />PERMIT # <br />LABORATORY NAME c <br />UC)IA - L COUNTY PHONE # ��� Jc�� - 1 On <br />SAMPLING FIRM <br />PHONE # c"- , <br />TANK INFORMATION <br />APPLICANT <br />TANK ID # TANK SIZE TANK CONTENTS PRESENT & PAST <br />DATE INSTALLED <br />39- <br />9-39-39-39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE C� TITLE hP,u J E L7 1�N (L—,\ DATE <br />❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME \ DATE \ <br />ANY DEVIATIONS F IS APPLICATI E SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (REVISED 08/13/99) Page 3 <br />