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9 <br /> SAN J JUIN COUNTY PUBLIC HEALTH ` RVICES <br /> tNVIRONMENTAL HEALTH DIVISIk. . N <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> AREMOVAL ❑ TEMPORARY CLOSURE Cl CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> NIEMEN- <br /> I ' PROJECT CONTACT � PHONEk 7 I <br /> EPASITE : G L o <br /> FACILITY NAME S PHONE 2orl 3 16 7 <br /> ADDRESSG rJ F ;r - S + Er <br /> CROSS STREET 1 t F _ <br /> OWNER OPERATOR ' P, PHONE % ZD lj ' L - �J <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME ' ORO `, r 1 i ?HONE ;x .ZOL Y / da <br /> CONTRACTOR ADDRESS O , O I I - I v CA LIC x '12 CLASS <br /> INSURER JRm4poP# I3 -7 y - S <br /> FIRE DISTRICT T STOL c. Fi E PRRVft I PERMITIF <br /> LABORATORY NAME C S C 1 0 - COUNTY ` vIX• v . PHONE # ZGL — LIE - OE+ `i L <br /> SAMPLING FIRM eCl . c, - C{ PHONE - CF L <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENTS iPRESENT S PAST) DA i'E INSTALLED <br /> 39- - I D IO, O r L.CaeLf -' <br /> j 39- it 1 7 09., CDz.CLE� <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE !AWS, FEDERAL TAWS. AND RULES AND <br /> :REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. ' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' '' II �lf/.f�I <br /> APPLICANTS SIGNATURE N� TITLE ! K 0 cc I DATE II' 34- qJ <br /> ❑ APPROVED :(APPROVED WITH CONDITION (S) ❑ DISAPPROVED <br /> (SEE CONDITICNS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME C/G � T/ C✓ �S DATES - 7 y� <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> ,(^.-C. , i L v� �C( � � CC�•�a � .J r�i � S A.P C�7/Z ` U <br /> � �� � I r � � QUA CCvtiC� � • Cf/7'Li <br /> =H 2 046 i EVISED 10G si ) ��� / �J Pagd 3 <br />