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SAN JOAQULN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> L REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> PAS(TE # �l�5��' PROJECT CONTACT & TELEPHONE # �� �/� �� �S �"-7 <br /> F FACILITY PHONE <br /> NAME 9� <br /> A h <br /> C ADDRESS U Trr-� <br /> I <br /> L CROSS STREET <br /> I <br /> i <br /> T OWNER/OPERATOR PHONE K i <br /> Y ! i <br /> CCONTRACTOR NAME PHONE # �l 1, <br /> 0 <br /> N CONTRACTOR ADDRESS i CA LIC ,Cy & 1 CLASS _ <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTRICT / I PERMIT ". <br /> T , �a <br /> 0 LABORATORY NAME 6., C� COUNTY ��� � r I PHONE # _ S-]1r <br /> R <br /> SAMPLING FIRM �� ((� frp PHONE # <br /> TANK <br /> tllllttltltltltltllttttl { <br /> TANK ID # TANK SIZE i CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- Al UeJU C. f <br /> A 39- <br /> N 39- <br /> K 39- i <br /> 39- <br /> 39- <br /> il1i111!(1(111111tllllllllllllllllfitttilllltlll tt{Itttltlllllltlltllliltlt1111111111tIIllllll1t1l1tlII1!lltltltllllll{111 <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> (% <br /> N PLAN REVIEWER'S NAME DATE l <br /> Ilttllllll Illlllllllt[tlilttllltilitltllllltllllll111111ttt111111111111illlltlitttt{lltllllttlilllllltlttllillt[!Itlllllltltt <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CA ." <br /> APPLICANT'S SIGNATURE: TITLE A ,/s a DATE w� <br /> Al <br /> r4; <br /> -EH 23 046 (Revised 9/11/96) Page 3 <br />