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SAN J ' AQUIN COUNTY PUBLIC HEALTH !:� ` RVICES � <br /> . NVIRONMENTAL HEALTH DMS 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 /> ,VIEMOVAL Cl TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT Cd9 144 [' PHONE# Zoy j 71( '"A/E^ Si <br /> FACILITY NAME LC{ (L�C- r i qF <br /> PHONE `L[I`) �ZU 7 ( S <br /> ADDRESS D TI <br /> CROSS STREET S <br /> OWNER OPERATOR 74b Eah PHONE # <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME SEMCO PHONE # 209- 524 - 9653 <br /> CONTRACTOR ADDRESS 1217 South 7th Street CA LIC # 449864 CLASSc 1 ZU4D.B A HAL <br /> INSURER State FU nd Insurance Coral a71 WORKERCOMP* 007108- 98 ASB <br /> FIRE DISTRICT PERMIT # <br /> LABORATORY NAME GeOAnal tical COUNTY St PHONE # . ( 209 ) 972- 0900 <br /> SAMPLING FIRM GeoAnal 1Cal PHONE % ( 209 ) 572- 0900 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br /> ;39 <br /> b 7 Z._ L /, �vv cru P & a5 u <br /> — z � I I , <br /> U 2 ' a3 [ 21b2ry n <br /> 0 2 l c <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 15 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 Tk PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATONLAWS O"LIIN�l <br /> APPLICANTS SIGNATURE TITLE " " DATE <br /> ❑ APPROVED AAPPROVED WITH CONDITION (S) Cl DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) ,�j <br /> (f"' /�.L� DATES <br /> PLAN REVIEWER' S NAME T � i <br /> ANY DEVIATIONS FROM THIS APPLJCATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> EH 23 Oa6 (REVISED 10119/98) Page 3 - <br />