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X <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGRCUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FRCM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE 3ELCW: <br /> p u <br /> �RE!fQVAL J�l� ��'-`� <br /> TEMPORARY CLOSURE CLOSURE IN PLACE <br /> IEPA SITE x (,p ) ,1 G�..1 p PROJECT CCHTACT b TELEPHONE #/1 <br /> I Andr��c�.ri �._ <br /> fAC:LlTY NAME - ��-S�� �� <br /> A �+� -`^ PHONE <br /> C ACCRESS <br /> CROSS STREET Lo , <br /> w <br /> i I ry WER/OPERATOR <br /> I Y ! �4 PHCNE x <br /> C CC,4TRAC7CR NAMEh(U 7 �►� I h Ect1 Il(� <br /> C I PHCNEit v. C� 1 7, L3 <br /> N I CONTRACTOR ACCRESS CA LIC �! <br /> T I CLASS A t1 <br /> R I INSURER 'G�1r$ /4 <br /> A 16cl;K.cCMP.# 4&020 ado <br /> C I FIRE 0ISTRIC7 <br /> QL <br /> PERMIT 0 <br /> C I LASCRATCRY NAME I j <br /> R i! OCA LC` I PHCNE # <br /> SAHPLING FIRM <br /> > -i <br /> t1i11111111I1111lt1IIIItI11I11 �_l , e/7Vit'L\ r��' '`- ( PHCNE U7� <br /> IANC !D TANK SIZE <br /> 34- CHEMICALS STORED TLY/PREVICUSLY DATE UST INSTALLED <br /> , <br /> I T 39- <br /> A 39- ` <br /> 39- <br /> 1C 39- <br /> 39- <br /> 39- <br /> P 1111111ti1! 111ItlI <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME `r --' (SE. TTACHMENT WITH CONDITIONS) <br /> 11 111 111111 i t 1111111 o DATE <br /> 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN AC=RDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCACUIN 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 BECCME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWING: <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 /> CCMPENSATION LAWS OF CALIFORNI . ' <br /> z� <br /> APPLICANT'S SIGNATURE: /' f x <br /> TITLE �� -Yc�1J• / <br /> - U C,ULj' DATE 7 f� <br /> EN 23 O46 (Revised 7/10/92) <br /> Page 3 <br />