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enVIRCNMENTAL HEALTH DIVISION <br />APPLICATICN FOR UNDERGROUND TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPCRARY CL SI1RE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM T APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # PROJECT CONTACT & TELEPHONEz <br />FACILITY NAME /I a ���V " ► L / PHONE (�/ <br />ADDRESS kD v ; /„ /a -_ J- <br />CROSS STREETAl �►/ ( iL� <br />OWNER/OPERATOR ^ ,� n y�_7,A_ 7L7 PHCNE <br />CONTRACTOR NAME �J p 5eA v PHCNE # <br />CONTRACTOR ADDRESS ?, /� /j e ! / o 40, 1 CA LIC # CLASS <br />INSURER V/ L /9 I , `l�munGc^d 7 7C/o6 <br />WORK.CCMP.# CA <br />ME <br />FIRE DISTRICT A /M// . /rr� r///pil PERMIT # <br />LABCRA70RY NAME Cil /�m-I - f � " ' ll PHCNE # Cfl� � / Z 3 � V � yD <br />SAMPLING FIRM G, - PHCNE # ql(o <br />fllfllllftflllillllllif <br />if III v <br />TANK I/ T I� SIZE L CHEMI SST ED RRENTLY�/PREVIOUSLY DATE UST INSTALLED <br />39 <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br />lllllillllfllllltlltfll!l11I11 lfltllfllltlilltll Iflltlltll 111llltlllltlllltllllifllliftlllttlllIt llltltll111111111111i <br />APPROVED <br />RS NAME APPROVED WITH CONDITION(S) DISAPPROVED <br />SEE TT E WITH CONDITIONS) 3 v <br />PLAN REVIEWEL�/{' ►' 1 DATE <br />ffllllitllllllllllii 1llllllllllil ItIlli!llfllllillllllilillllflilllilllllfllliflf1111ftllllill11111 11lllllfllllfll <br />PPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />UBJECT 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 />OMPENSATION LAWS OF CALIFCRNIA." <br />ICANT'S SIGNATURE: _�� TITLE ��:. DATE <br />123 046 (Rev 2/8/91) ft Page 3 <br />