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' P <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE 1N ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> i <br /> Y REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA S13E ;'c AC o J - / PROJECT CONTACT $ TELEPHONE # <br /> AFACILITY NAME Lam' G�1 4 PHONE <br /> C ADDRESS ?�s I� Cf3 <br /> I tJ I, 74 <br /> L CROSS STREET ; <br /> I <br /> 70WNE:R/YPERATOR F PHONF # <br /> C CONTRACTOR NAME -" F <br /> �' `i_ .tc C PHONE # �-� <br /> 0 1` <br /> N CONTRACTOR ADDRESSCA LIC #3�j o CLASa(=C <br /> T <br /> R INSURER � e I1 I WORK.CCMP.# 0 <br /> C FIRE OISTRICT �r PERMIT # W <br /> T tMe <br /> R LABORATORY NAME1.� COUNTYfk <br /> ` f PHONE <br /> SAMPLING FIRM � � .1 ! PHONE 9 <br /> lI1I111111IIIIl11, lli ! ll N <br /> TANK [D # TANK SIZE CHEMICA STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> �i <br /> A 39- ie <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9- <br /> 39-39-P 1I11111ii1I!llilll I 111!1 I !1 I IIIIIll ! Il !1 !1 I1111111l�llllll.l I 11111111 1 Illlllll11111 11111 <br /> L APPROVED i—APPROVED WITH CONDITION <br /> S) `R_ DISAPPROVED <br /> A (SEE ITION BELOW AND/OR ON ATTACHMENT) <br /> N r� p <br /> PLAN REVIEWER'S NAME DATE L�U <br /> IIIIlillllllll11fI1l11111 IlIill ! 111illlllll[1i1111llIIIIl111111[IIIIIIIIIIIIIIi!llII111Illlll111llllllllllllll <br /> APPLICANT MUST PERFORM ALL WORK IN CORDANCE WITH SAN JOAQUIN COUNTY OROINANCES,' STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY HEALTH SE ICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF TH R HIC '%THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECCME <br /> SUBJECT TO WORKER'S COMPE TION LA LIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFO NCE OF HE WOR CH THIS PERMIT IS ISSUED, 11SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL R k <br /> APPLICANT'S SIGNATURE: TITLE DATE Cz_ <br /> ONDITION(S): <br /> r <br /> 3 <br /> 5 <br /> I <br /> � f <br /> c.1 23 046 (Revised 9/11/96) Page 3 <br /> f <br /> 4 <br />