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SAN JOAQUIN • HEALTH <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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />-L REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />PLAN REVIEWER'S NAME r DATE _ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SANJOAQUIN 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 CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE AL' -,EO -1 Foil_() kk t:FZ DATE <br />cormrrioN( t • S 4 <br />'� <br />EH946Revise(d 9/1 /96) P g-3 Ay zolo <br />iq-1-741�Vtz � ;4 & <br />EPA <br />PROJECT CONTACT & TELEPHONE #--� <br />F <br />FACILITY NAMEao <br />PHONE <br />_ <br />A <br />C <br />ADDRESS i <br />I <br />L <br />CROSS STREET ` L c�, 1 \ <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />CONTRACTOR NAME- r>--- U CK -f U S�Z <br />PHONE <br />0 <br />N <br />CONTRACTOR ADDRESS pO <br />CA LIC #-75 <br />CLASS <br />T <br />R <br />INSURER <br />` ^ <br />WORK. COMP. # <br />A <br />C <br />FIRE DISTRICT. -� `, <br />--0 <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME <br />CCOUNTY <br />kd <br />PHONE # I� -7 (�8 �O <br />R <br />SAMPLING FIRM J\a A G�LN <br />C.NVIRON'At:N kN- 1N G <br />PHONE # zo <br />_ O <br />TANK ID # <br />TANK SIZE CHEM CALS STORED CURRENTLY/PREVIOUSLY <br />�\ <br />DATE UST INSTALLED <br />39- <br />I U <br />. by �) E 1_ <br />L� �11!� <br />T <br />39- -- <br />47 <br />241U <br />LEP`\aT <br />i✓ <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />""!1' <br />L <br />APPROVEDAPPROVED <br />WITH CONDITIONS) _ <br />DISAPPROVED <br />A <br />_ <br />( EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />M <br />1 <br />PLAN REVIEWER'S NAME r DATE _ <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SANJOAQUIN 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 CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE AL' -,EO -1 Foil_() kk t:FZ DATE <br />cormrrioN( t • S 4 <br />'� <br />EH946Revise(d 9/1 /96) P g-3 Ay zolo <br />iq-1-741�Vtz � ;4 & <br />