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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> {CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT 1NP.ITE IN.ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> IX REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY IIJFORMATIOH <br /> EPA SITE# PROJECT CONTACT j''3LA2 Q12LP LL.% PHONE# �� �iID <br /> FACILITYNAME Fccp gmlpfy) <br /> PHONE# ' OCA - . - 2 <br /> ADDRESS CX <br /> CROSS STREET c-a <br /> OWNER OPERATOR + S'�' PHONE# Cjl -`�4R- <br /> COl',,]TRACTOR II'1FORMAT101'\1 <br /> CONTRACTOR NAME 1i PHONE# q-Sq`? Itc <br /> CONTRACTOR ADDRESS p,D 3 L"D • y 1 CA LIC# ,C CLASS RPC,10" <br /> INSURER E cv\c �`\CLI�� S '[+ul U� nC WORKEP, COMP# U 1 lll. <br /> FIRE DISTRICT PERMIT# <br /> LABORATOP.YNAME ITCO nJ La}a COUNTY GiC in PHONE# <br /> S.AMPLINGFIRM 7�rn[:.� i O �n}c+l PHONE# Ot - - CA <br /> TAPNK INFORMATION <br /> TANK ID# TANK SEE TANK CONTENTS(PRESENT AND PAST DATE INSTALLED <br /> 2 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK N ACCORDANCE WITH SAN JOAQU N COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOYANYPERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR. SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS TO WORKER'S COM NS TIO LAWS OF CALIFORNIA" '` <br /> APPLICANT'S SIGSUBJECTTITLE DATE <br /> M APPROVED 'I ,APPROVED WITH COHDITIOI".I(S) ❑ DISAPPROVED <br /> (_SEE COND.. NS BELOW ANDIOR OPJ ATTACHMENT) <br /> PLAN REVIEW'ER'S NAME J DATE � <br /> ANY DEVIATIONS FROM THIS APPLICA N MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br />