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I <br /> SAN JOA\ .N COUNTY PUBLIC HEALTH SE ICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 /> d REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE; PROJECT CONTACT -177PHONE# �j AA <br /> FACILITY NAME PHONE# <br /> ADDRESS V <br /> CROSS STREET <br /> OWNER OPERATOR PHONE# • 14�� <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME `\C3n� PHONE# `Z y <br /> CONTRACTOR ADDRESS _ q►� A LIC# j\ CLASS A <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME COUNTY PHONE# <br /> SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- <br /> 39- <br /> 39-'t <br /> 9-39- <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 AGENTS 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: '1 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 /> APPLICANTS SIGNATURE /' / I TITLE%C��-C rcOZ�O 1`3��Q DAT>e <br /> ❑ APPROVED In APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE -� <br /> ANY DEVIATIONS FROM THIS APPUCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> NDITIONS <br /> a f7 re t t1�a t n, SUS 66, v%'►(��l t-Y�' /i K c 1' <br /> Z 'uf( 1,4�4di ht>(.C/a 1 f pt;'�/,Q V�. /�� �,,�, 7.�-� AS /: w elf <br /> jG�1 C ; f,�, <br /> ift,ole (ic it9acr o:C1111 ' 111,44 tr , Cj�'f /1t o Acw e <br /> i jc d t'(' c Ft_b tx -I-11i (�( b - <br /> .. < (,11 tv- L 14' ! !l /.SG 2 (' <br /> l:(ri i IIi1Po�r'4'4l�/� fiGtli <br /> 23 a6(REVISED 10/19 .' P e 3 <br /> /'c-t(�L' OIL) <br /> ED ItoI/98�,IIc�i�t.//� � �Ur��� <br />