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SAN aQUIN COUNTY PUBLIC HEALT' ERVICES <br /> ENVIRONMENTAL HEALTH DIVISiON <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 /> �REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> J FACILITY INFORMATION <br /> EPA SITE# Z PROJECT CONTACT V �- PHONE# Yy— <br /> FACILITY NAME PHONE# <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR /' - PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# <br /> CONTRACTOR ADDRESS CA LIC# CLASS Ic <br /> INSURER WORKER COMP# <br /> FIRE DISTRIC PERMIT# <br /> LABORATORY NAME 5 COUNTY S-kff PHONE# <br /> SAMPLING FIRM I PHONE q- a <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- /' (lhKr►�lu/h <br /> 39- — :�. U i o ✓� <br /> 39- If !Ly►�CcJh <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <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: 'I 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..'' `i_I-� , -+ <br /> APPLICANTS SIGNATURE ti'��' A-+.t.Ll TITLE DATE <br /> Cl APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME (��1! DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE S BM TTED TO EMD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: R <br /> EH 23 046(REVISED 10/19198) Page 3 <br />