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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />RE OR TANK <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSUADATE NM00 NOT NRI E ENT IN PLACE OUNDERGROUND <br />ANCE SRAG <br />IN ANYSHADED AREAS. INDICATE PERMITTOTYPEcBELOW' <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />PROJECT CONTACT & TELEPHONE '� `,,-0&& t PcI l 1 i' l- a p + 14 <br />EPA S %7E # �� p Z O i' ± ►•� 3 2. I PHONE <br />—13-3 Z <br />F FACILITY NAME Li 4,:,, ._ S L' <br />A <br />C ADDRESS 210) yf. p,�•}-i % .� s' <br />I <br />LCROSS STREET 1 �-f ,ia <br />I I PHONE $ <br />T OWNER/OPERATOR <br />P2� <br />FS) SS $�-' - X2'2' <br />Y b YaiGr S 1.o1�P.AlJ z. Ei) <br />I PHONE # C k o5) 3 L+ " <br />C I CONTRACTOR NAME VA�p7eo,. <br />'.!J asil �: Lo. CLASS <br />0 I CA LIC # (p 1 1 �i `') 4 P <br />Y CONTRACTOR ADDRESS fRjp�j 2S►i'g Sd.tJ A MQ'�% <br />I WORK. COMP. <br />R INSURER (111Or1� tj(Y`G.`(Z Fa1,j.S {--y2- GHQ' I PERMIT #. I <br />A <br />C FIRE DISTRICT G I Q� .� CTG• n.� <br />T I PHONE # tj 1 Q lg p io 4'1 !o O <br />0 LABORATORY NAME sL-- <br />I PHONE <br />I RA ✓ r1 -o <br />SAMPLING FIRM p ��� <br />II11t11111t111111111t1t1t1111 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY OATS UST INSTALLED <br />TANK IO # <br />�Iv % <br />T 39- > — i <br />A 39- <br />H 39- 1 <br />K 39- <br />39- <br />3911 1 1 t IIIi�T�il til 11 1111 1 11 1 tl 1 I1t111 fU 1 Ittli 111111111111lt111 11111111111111111111 <br />P 111 APPROVED WITH CONOITION(S) __, DISAPPROVED <br />APPROVED <br />L (SEE ATTACHMENT WITH CONDITIONS) DATE <br />A ?LAN REVIEWERS NAME 11111 <br />NuIlluffmI <br />I I I I I I 11111111 111111 <br />STATE LAWS, AND RULES AND REGULATIONS Of <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACU%N COUNTY ORDINANCES, <br />"I CERTIFY THAT IN <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE SUCH A MANNER FOLLOWING: TO <br />THE PERFORMANCE OF THE WORK FOR WHICH <br />OFOME <br />ICALIFORNIAS,ISCOmRACTORASLHIRING OR SUSCONTRACTINGNOT EMPLOY ANY PERSON NS SIGNATURE CERTIFSES THE C FOLLOWING: <br />NG <br />SUBJECT TO WORKER'S COMPENSATION LA <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 />TITLE �- DATE <br />APPLICANT'S SIGNATURE: <br />Page 3 <br />EH 23 046 (Revised 4/26/94) <br />