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Y � <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 4 REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # Q Ot! `��8 PROJECT CONTACT & TELEPHONE # ,/c,,/A,-1 T <br /> F FACILITY NAME _ PHONE <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T I OWNER/OPERATOR PHONE # p <br /> C CONTRACTOR NAME �� PHONE <br /> 0 COO <br /> N CONTRACTOR ADDRESS t CMZ d? „tJ/� CA LIC # J CLASS ��/)2 <br /> T '�/ 7 <br /> WORK.COMP.# <br /> A INSURER TR%C �/3?r� i/P1 %'� � �/�-UPS` f�'�� <br /> C FIRE DISTRICT 1�EJTCC/� PERMIT #. <br /> T <br /> 0 LABORATORY NAME E COUNTY��� ��� �,,�, PHONE fJ� -3 2—7, (ol' <br /> R <br /> SAMPLING FIRM PHONE # <br /> TANK <br /> Illlflllllllllilllllllll <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T <br /> 9 <br /> A <br /> N 39- <br /> i <br /> K 39- <br /> 39- <br /> 39- <br /> Iltlifllillllllllllllllllflll! I illlllll11111 1lII 111111 I II111 III IIIIIIIIII1111lIIIIII11111 Illllilillllllllltlll <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (Stt CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE � `7 <br /> 11111111 i l l i 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: , L TITLE fl .cJ T DATE <br /> CONDITION(S): <br /> 1D ,, e`er° <br /> EH 23 046 (Revised 7/10/96) Page 3 <br />