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SAN JnAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> VVIRONMENTAL HEALTH DIVIS , <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> " EMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE # PROJECT CONTACT jVtl G4'7 PHONE Z224 j Zy -yE' S7i <br /> FACILITY NAME LLCLU PHONE Z!I ) S ZG C( J . <br /> ADDRESS D //'/'7 - E( W &D t7f, :I'C A <br /> CROSS STREET 5`fq <br /> OWNER OPERATOR PHONE # <br /> r7 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME SEMCO PHONE # 209- 524- 9653 <br /> CONTRACTOR ADDRESS 1 21 7 South 7th Street CA LIC # 449864 CLASSC 1 A HAZ <br /> INSURER State Fund Insurance Company WORKER COMP# 007108- 98 ASB C <br /> FIRE DISTRICT PERMIT # <br /> LABORATORY NAME GeOAnal tical COUNTY St PHONE # 572 - 0900 <br /> SAMPLING FIRM GeOAnal tical PHONE k 209 572- 0900 <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- lb92. -03 ( ZI Ut)z <br /> 39- p oce ergo L ' <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: 1 <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 LIF <br /> APPLICANTS SIGNATURE TITLE �Z V DATE <br /> I <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME l' �,--�/O� L/d /� DAT <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> / CONDITIONS : <br /> cam" t� <br /> EH 23 046 (REVISED 10/19/98) Page 3 <br />