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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE P IT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDO BSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDI ERMIT TYPE: <br /> ❑ REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSUR LACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT IPHON <br /> FACILITY NAME PH <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR ONE# <br /> CONTRACTOR INFORMATIO <br /> CONTRACTOR NAME PHONE# <br /> CONTRACTOR ADDRESS Ok AV LIC# CLASS <br /> INSURER WORKE <br /> FIRE DISTRICT PERMI <br /> LABORATORY NAME CO PHONE# <br /> SAMPLING FIRM P <br /> TANK IN ATION <br /> TANK ID# TANK E TANK NTS PRESENT& PAST DATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK I DANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COU IRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJ WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLL "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO 'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATUR TITLE DATE <br /> ❑ APPRO ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVI NAME DATE <br /> ANY TIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23,046 (Revised 12/31/07) 3 <br />