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LSAN JOAww IN COUNTY PUBLIC HEALTH SE /ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> L <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> Li. <br /> 'REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN-PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT R,41e 417-rGE PHQNE L 2G �5�,/�Z9ZZ <br /> FACILITY NAME �� ST Gyf,Q.Y (,✓1¢ PHONE <br /> ADDRESS 7S T 1/AG PYrO X> vim T,p� Fr3 7.6 <br /> CROSS STREET 'I T i/ <br /> OWNER OPERATOR E Sr �.•i/�L��el� PHONE ?-76 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE VIOL,;— u <br /> CONTRACTOR ADDRESS 7-oVo f � CA LIC# 75 CLASS ,0 ' I <br /> INSURER WORKER COMP# <br /> FIRE DISTRICT CY <br /> ? PERMIT# <br /> LABORATORY NAME v COUNTY D.Ac v S PHONE# 3; <br /> SAMPLING FIRM PHONE k 7,07) 6 y <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> .39- <br /> 39- <br /> 3 <br /> 9- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> ke:ERPPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> TIFY <br /> EGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> 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 /> '0 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> NE FOLLOWING;: 'f 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,' <br /> -. 4 :I <br /> PPLICANTS SIGNATURE TITLE ,.. DATE/?- � f& <br /> ❑ APPROVED RrAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> �I (SEE CONDITIONS BELOW AND10R ON ATTACHMENT) <br /> LAN REVIEWER'S NAME LOATEt� <br /> I c1�; <br /> II <br /> ANY DEVIATIONS FRONI.THLS APPUr-ATION MUST'SE SUBMITTED TO END FOR APPROVAL PRIOR TO COM <br /> MENCING WORK. <br /> } CO � <br /> IN IT10NS: _ <br /> or Ll7r1_rhl <br /> n t^I,{Y.l✓� � r�� i iJ�ifTJ <br /> E�?3 046(REVISED 10119/98) Page 3 <br />