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SAN JJUQUIN COUNTY PUBLIC HEALT RVICES <br />NVIRONMENTAL HEALTH DIVISIM <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 />0 -"REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />5�r5' <br />APPLICANT <br />FACILITY INFORMATION <br />- <br />EPA SITE #c'�n <br />PROJECT CONTACT fl fl `' _ ' c' /i' <br />PHONE# (` ' S41 <br />FACILITY NAME r E r - <br />S i J.' .'T /C� 1)( -PC, w - j n <br />PHONE # <br />ADDRESS '�; %7 i- . <br />i -, <br />L <br />CROSS STREET "r - <br />': <br />WORKER COMP#, <br />OWNER OPERATOR i <br />.; ' : ' <br />PHONE#,, <br />5�r5' <br />APPLICANT <br />CONTRACTOR INFORMATION <br />TANK ID # <br />CONTRACTOR NAME <br />_ <br />PHONE # /.4 6 ' - 6 �} <br />CONTRACTOR ADDRESS <br />39- T,.4- <br />CA LIC # G! 3i i 7 - I CLASS <br />L <br />INSURER Ai <br />': <br />WORKER COMP#, <br />%-� <br />FIRE DISTRICT <br />VC G 3 9 - qq <br />1,)PERMIT # <br />139 <br />LABORATORY NAME L- L c r 1V <br />%�C&,'V J- i /� /j S <br />COUNTYS/- 4 f, jqp i & T j <br />PHONE #; /,/C j <br />SAMPLING FIRM r <br />-/y <br />PHONE # <br />5�r5' <br />APPLICANT <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) <br />DATE INSTALLED <br />39- T,.4- <br />�- <br />L <br />39- <br />9-39- <br />39- <br />39 <br />3939 <br />139 <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 AGENT'S 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." <br />APPLICANT'S SIGNATURE TITLE C�J� L i'��/r r/L /✓_S ��i.•'h"/1c "blA - <br />�. . <br />❑ APPROVED XAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />• (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAM 4Vj��DATE <br />ANY DEVIATIONS FROM THIS APPLICAT19 MUST B UBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />O%�iD7m"I"I^ONS: <br />zkickad C"atf <br />EH 23 046 (REVISED 08/13/99) Page 3 <br />EH 23 046 (REVISED 08/13/99) Page 3 <br />