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SAN JC JUIN COUNTY PUBLIC HEAL— S RV;ICES <br /> V' O P.;)!E N II A.LLTH.. DIS. �,l <br /> r;PPL1CATION 1707UNrjE—?GRCUND S T ORt=. ,E CLGSURE PERMIT <br /> THIS PERMIT FOR PcRMANENT/T=-MPCRARY CLOSURE OR,ABANDONMENT IN PLACE O= OERGRCUND HAZARDOUS SUBSTANCES <br /> STC.-RAGE TANK(S) EXPIRES 90 DAYS FROM,THE APPRO"41-CATc. CO NOT'NR'T E!N A ,HADED AREAS. INCICA i E-PERMIT YPE: <br /> 'REMOVAL ❑ TEMPORARY CLOSUF CLOSURE IN PLACE <br /> FACIL!Tv, !NFORMATION <br /> EPA SITE ZZ?, PROJECT CONTACT -fritts: ?✓CNE7 <br /> FACII-17Y .NAVE I `r �;�� =ACNE <br /> AOCRESS <br /> CTRE- S <br /> :, iER PERATCR ,� _ tii ?-CNE#00c:?'— <br /> CONTRACTOR <br /> 0c:?'—CO`6TRACTOR !NFORMA,T iO <br /> CONTRACTOR NAME �oc 0•t�l� �/Cc ��-l�-s^r�t �• P `CNE :*009 y^ <br /> CONTRACTOR?.DDRESS,� � (Qr4 �~`. C' <br /> •r <br /> 'NSURE ;C I '/VCP.KER CO^APT <br /> =IRE DISTRICT �-1,_t Com-' S'��-cD� i ?ERPr1T T -- <br /> LABCRATCRY ,NAt•Ac �� " <br /> SAMPLING FIRM y6rl�GF.� �Yr. � •4YrdLo��u'1tTT PHONE ZG<:f !-f n?- Od <br /> TANK INFORMATION <br /> `aNK IC' TANK S1ZE -a.tiK CCNTcNTS PRS ENT T) DATE: iNSTAL'_ED <br /> 39— )UEO <br /> i I <br /> 39— <br /> 39- <br /> 39— I <br /> APPLICANT'AUST PERFORM ALL WORK IN ACCCROANCE''fJi" SAN JCACU!N COUNTY ORCINA.", STATE LAWS. FEDERAL LA'NS.AND RULES AND <br /> �EGULA1�CNS OF SAN 'CACUIN COUNTY PUBLIC HEALT' SERVICES. --WNER OR LICE*!S'cD .. S SIGNrTL'P.E CER'IFiES HE FOLLOWING: <br /> CERTIFY THAT IN THE PERFORMANCE OF TrIE''.VORK FOR,', IC;-i i, IS PERMIT IS ISSUED. I S.-HAL:. T EMr_L%.v ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUB.IECT-0 WORKER'S COMPENSATION LA'•VS OF CALIFGRNLA,' CONTRACTOR'S 3 OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWNG: 'I CERiIF!TNAT!N THE°ERFORVtAQJCE C^Tr!=:YORK FCR WHICH T HIS PERM SU=:). SHALL EI.1PLOY PERSONS SUBJECT TC <br /> NORKER'SCOMPENSATION V13j�24aL1E:'ZH (I <br /> APPLICANT'S SIGNATURE / � TITLE <br /> ❑ APPROVED APPROVED WI T'r! CONDITIONI 77 DISAPPROVED <br /> (SE.CONDITIONS BELOW AND/OR ON: :HMENT <br /> I <br /> t PLAN REVIEWER'S NAME I \ �G���LS+� DA i c / <br /> i <br /> ANY DEVIATIONS FROM THIS APPUCATICN rMU'ST BE SUBMITTED TO EHO FOR Ar JVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> I-=- <br /> I V V <br /> V 1 <br /> I <br /> I <br /> EH 23 Ods(REVISED 'Cl19i99j -- ?age 3 -- - - - - - — - -- <br />