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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 /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE cc'� 11,, 77 <br /> EPA SITE R ��OGC�jj .PROJECT CONTACT & TELEPHONE X I `�K UI L�i %`4j4-,3- <br /> F FACILITY NAME � (� Fb� PHONE XC C-eA'4'( <br /> A <br /> C ADDRESS rZi CI-M � al <br /> L CROSS STREET ' 'l <br /> I <br /> T OWNER/OPERATOR Lgt ` <br /> qu.L(R.((� �S PHONE tS_q� J�I Z' <br /> Y C J <br /> C CONTRACTOR NAME SEMCO PHONE N 209 524-9653 <br /> nC61 D40 B A HAZ , <br /> N CONTRACTOR ADDRESS 1217 S. 7th St, Modesto, CA 95351 GA LIG s 449864 Glass 57 <br /> T 1 R INSURER Insurance Company WORK.CONP.X <br /> A <br /> C FIRE DISTRICT PERMIT X <br /> T <br /> 0 LABORATORY NAME (oA]alvtical Lab. COUNTY Stanislaus PHONE X (209) 572-0900 <br /> R PHONE x (209) 572-0900 <br /> SAMPLING FIRM CieOAnalyt].Cal .Lab I <br /> TANK ID A TANK Sj3E CHFsM(lL STORED CURRENTLY/PREVIOUSLY DATE U T INSTALLED <br /> 39- d -CJ !d o-a-o (WJa <br /> T 39- t v Ah - 2 / PK — cXWQYti R,1 ! <br /> A 39- 1 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39 <br /> L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> + A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> N . <br /> PLAN REVIEWER'S NAME GATE <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 AMANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION (AWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; <br /> "I CERTIFY THAT IN THE PERFORMA E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI � 1v� yq F <br /> APPLICANT'S SIGNATURE: TITLEa 6U " DATE <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> �'�� dz co1e1L�•�� ,�v�L; SfGf� ��. <br /> p4.c./ 67 �F_�sEcs�o �/ ls/v� s / ✓� t�E ��T /ywti56�' 'ro� <br /> EH 23 046 (Revised 9/11/96) Page 3, <br />