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SAN JOAQUIN COUNTY PUBLIC I IFAI`I I I SFRVIC:F.S <br /> ENVIRONMENTAL HFAL_TI I I)IVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEmrORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> O REMOVAL O TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT PHONE#Z0'?=y6�=� <br /> FACILITY NAME � ` -� ------—--------- PHONE It <br /> ---------------- <br /> ADDRESS 7— <br /> CROSS <br /> CROSS STREET <br /> OWNER OPERATOR yw PHUNE <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME�TnC _� __� `ST—r_ _ <br /> CONTRALTO ADDRESS CC��1___c ___ <br /> y�� _. ._.._.._-.-..L <br /> R CA LICA �OQ1Q S�__-i_CLAS�6� <br /> / C) WURKER LUMP# <br /> INSURE !r � 4 ��� -- -- <br /> FIRE DISTRICT <br /> LABORATORY <br /> S _— _—_ �'ERMIT# <br /> LABORATORY CUUNTY,4 L� PfIONE 25—_ <br /> SAMPLING FIRM v <br /> PHONE N d' <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE —TANK CONTENTS LRESENT& PAST) DATE INSTALLED <br /> 39- - ----- _ - - --- <br /> 39- ------- --- --- <br /> 39- --- --- ------ --- ------- -- -- - <br /> 39- -- - - - - ------ <br /> --- --------- <br /> 39- -- --- --- -- --- - <br /> 39- --- - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORFIANCE WIT I SAN JOAOUIN COUNTY ORDIIIANCES, STATE LAWS, FEDERAL LAMS.AND RULES AND <br /> REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES TIIE FOI(OWING -1 <br /> CERTIFY THAT IN THE PERFORMANCE OF 111E WORK FOR WI-IICH THIS PERMIT IS ISSUED.I SHALL NOT EKirLO'Y ANY PERSOtJ IN SUCtJ A MAtJIJER AS <br /> TO BECOME SUBJECT TO WORKERS COMPENSATION LAWS OF CALIFORNIACONTRACTORS AIRING OR SUPCONTRACTING SIGNATUPE CFRTIFIES <br /> TIIE FOLLOWING 'I CERTIFY THAT IN 111E PERFORh4ANrF OF TIIF':IORK FOR WIIICII THIS PFRAIIT IS ISSUED,I SHALL FKirl O-Y PFRSONS SUBJECT TO <br /> WORKERS COMPENSATION LAWS OF CAI IF(1Rt11A' <br /> APPLI(;ANT'S SIGNATURE.. (III P ITAIF <br /> O APPROVED O APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME <br /> ---- ----------------- <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EFID FOR APPROVAL PRIOR TO COMMENCING WORK- <br /> CONDITIONS: <br /> I <br /> FI1 23 0i6-(REVISFD OfIi13/99) <br />