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SAN JO UI AUNTY PUBLIC HEALTH S ' VIrr7S <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 /> f3REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> CAGooZZZZ2gt7 FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT PHONE# Loy- <br /> FACILITY NAME rc7 PHONE # <br /> NIA- <br /> ADDRESS 4'O O . ZO ,G <br /> ftS STREET L( ja - U45y <br /> OWNE 6 <br /> )OPERA- <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Chi. �[. , PHONE q# <br /> CONTRACT R ADDRESS jD , �• CA LIC S 9Z CLASS <,Q Z <br /> INSURER e-Xf471% ' tAA'2)lhe WORKER COMP# <br /> FIRE DISTRICTC, PERMIT # <br /> LABORATORY NAME 9 1-� IY �t COUNTPHONE # <br /> SAMPLING FIRM n .1 r . PHONE It — Od <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br /> 39- / L) Q 26 , LA Nt-rc^,:D <br /> 39- ' O 00o URtw h <br /> 391 eq Lo -2, Lt a o 0 VA LkAD <br /> 39- io ? z-bq 24 oo o r <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORD NCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLI H LTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 <br /> I CERTIFY THAT IN THE PERFORMANCE OF THEW RK FOR WHICH THIS PERMIT 15 ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> I TO BECOME SUBJECT TO WORKER'S OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT I PERF NCE OF FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION O AL ORNI . 1 <br /> f APPLICANTS SIGNATURE TITLE DjT A143 4m L DATE 9 <br /> El APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME P�, n �t` Dn DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> S� C ti , <br /> vim, cwL w <br /> EH 23 046 (REVISED 10/19/98) Page 3 <br />