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FRCM ' TAIT & ASSOCIATES - Sacramento FAX NO. . 9166352606 Apr. 29 1999 07:23AM P2 <br /> SANJOA ,'' COUNTY PUBLIC HEALTH SEP' 'CES <br /> ENV <br /> I�tONMENTAL HEALTH DIVISION <br />'• APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> ITIS PERMIT FOR PERMANENTITEMPOPARY CLOSURE OR ABANDONMENT IN PLACE OF UNOERGROUNO HAZARDOUS SUBSTANCES <br /> FORAGE TANK(S)EXPIRES 90 PAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TYPE. <br /> E3 REMOVAL ❑ TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA STTE PROJECT CONTACT l % Z <br /> FACILITY NAMES 1 C-0 PHONE - 30 <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR S G V PHONE iF 6 4(.9 ~ uz, <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME v\CIt ;-r%;ijpjj 'L Z PHONE <br /> CONTRACTOR ADDRESS G S LCA UC V 3o b 5 CLAS5C-Co X <br /> INSl11iER A d, t WORKER COMPS <br /> FIRE DISTRICT 't i0 PERMIT# <br /> LABORATORY NAME c ej� L L COUNTY PHONE z S -I <br /> UNCI FlR - - L PRONE ?-6A go - I f204 <br /> TANK INFORMATION <br /> TANK10# TANK 512E TANK CONTENTS PRESENT a P TE INSTALLED <br /> 39- �. <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MU$T PERFORM ALL WORK IN ACCORDANCE►ATH BAN JOAQUIN COUNTY ORDINANCES STATE LAWS FEDERAL LAWS.AND RULES AMC <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUSUC HEALTH SERVICES. OWNER OR UC04ED AGENT'S SIGNATURE COMFIES THE FOLLOWING 'I <br /> CERTIFY THAT 1N THE POWORMANCE OF THE WORK FOR V"CH THIS PERMIT IS ISSUED.I SMALL NOT EINPLOV ANY pERSON IN SUCH A MANNER AS <br /> TO BECOME SUWECT TO MMORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING 516NATURE C€RTIFIES <br /> THE fOLLOV4RNIG 9 CERTIFY THAT IN THE PERFORIMANGE OF THE VMORK FOR WHICH THIS PF.RWT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CAUFORNIA' <br /> APPLICANTS SIG �NATIJRTME.K r=eNZ Rts0. OWuLt GATE <br /> APPROVED APPROVED WITH CONDMON(S) © DISAPPROVED <br /> IEEE CONDMONS 8ELOW ANDNM ON ATTACMATENT) <br /> PLAN ReVIEWER'S ANY DEVIATIONS FROM THIS APPLICATION"LIST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO C12M?MNCINg WORK. <br /> CONDITIONS: <br /> oh o <br /> a <br />