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1 SAN JOAQUIN COUNTY PUBLIC I IFAI- 'I1 SFRVIC:ES <br /> ENVIRONMENTAL HFAIA I I [)IVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLATE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIRES 90 DAYS FROM THE APPROVAL DATE 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT S _ __. PIIONE#ZOO( C�= <br /> FACILITY NAMES PHONE a <br /> ADDRESS � _ ---- - -- ---- -- <br /> CROSS STREET <br /> OWNER OPERATOR / PHONE #ZO 9-qZ— Z <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME -- PH_- --���z ST1_F .�_----- — UNE # <br /> CONTRALTO ADDRESS ,, rr i CALIC_aOQ[d <br /> 61 <br /> CON <br /> INSURERWORKER LUMP#-�� ✓��( <br /> FIRE DISTRICTccn <br /> PERMI T'a <br /> LABORATORY NAME _COUNTY PHONE �, 6 Z� <br /> SAMPLING FIR M��} �F &J PHONE H D� <br /> TANK INFORMATION <br /> TANK ID a TANK SIZE -—TANK CONTENTS(PRESENT & PAST DATE INSTALLED <br /> 39- --- — --- -- -- <br /> 39- --- <br /> - --------- <br /> 39- - — ----- ---- --------- -- <br /> 39- --- - -----—----- ----- <br /> 39- -- -- -- -- --- -- <br /> APPLICANT MUST PERFORM ALL WORKIN ACCORnAtICE VJItII SAtJ JnAOUIN COUNTY ORDt1JAtICES. STATE LAWS. FEDERAL LAWS.AtJD RULES AND <br /> REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HFALTII SERVICES OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES TILE FOI LOWING .I <br /> CERTIFY THATIN THE PERFORMANCE OF TIIE WORK FOR WHICH THIS f FRhIIT IS ISSUED, I SHALL NOT Eh1PLOY ANY PFRSON IN SUCII A MANNER AS <br /> TO BECOME SUBJECT TO WORKERS COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS 111RING OR SURCONtRACTING SIGNATUPE CERTIFIES <br /> TIIE FOLLOWING 'I CERTIFY THAT III TIIF PERFORMANCF Or THF PJORK FOR WI IICII TATE f FRhIIT IS ISSUFD.I SIIAI L F:P.IPI n' PERSONS SURJF.CT TO <br /> WORKERS COMPENSATION LAWS Or CAI IrnRt11A' <br /> APPLI(;ANT'S SIGNATURE 1111 F ()AIF <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEF CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME------.--- —_.—_.-_ DATE--- <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> F.FI 21046(REVISFO 08117/99) -- Pngrt 3 <br />