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• <br />ENVIRONMENTAL HEALTH DIVISION'-; <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />�1 <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARD861S1`6 , _AN�fA(�'T'ORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERM -TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLO)I6RE�NVfft�MFNTAT <br />EPA SITE # II tDoi�J (T3a PROJECT CONTACT & TELEPHONE # NOj(lT <br />MQA -[i[� -' <br />F FACILITY NAME L IOC l _55'lk�PHONE #a-Dq- 4f 73-7337 <br />C ADDRESS�O/a��7n;/� 95at9 <br />I <br />L CROSS STREET S <br />I <br />T OWNER/OPERATOR ^ PHONE # <br />Y {/ Co S18-854 -7©a•? <br />C CONTRACTOR NAME^� PHONE # 2V4 -9X -33M <br />N CONTRACTOR ADDRESS /¢19��/� .Dlra ,r CA LIC # /95787 CLASS A <br />T <br />R INSURERWORK.COMP.# <br />A <br />C FIRE DISTRICT C + 5�oG6tzn / PERMIT # <br />T <br />0 LABORATORY NAME A A <br />RAOL PHONE # <br />SAMPLING FIRM PHONE # / <br />11111111111111111! 11111111111! <br />39 - <br />TANK ID # TANK SSE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T 39-) t r% <br />A 39 -IF I <br />N 39- <br />K 39- <br />39- <br />39- <br />1111l1111111l111!lliill11111l1 11!!1! I 1 IllllI1111111111111 I111111111i111i1111111111i1111111111!!I 1111lIIl111111111!!1! <br />P <br />L _ APPRO __APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE AJIAI;HMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME w -" ' t DATE i , f� <br />IIIIIIIIIIIIIIIIIIII Illllm <br />t <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 COM SAT ION S OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE E A F THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CA F N .' <br />APPLICANT'S SIGNATURE: TITLE DATE 10/0q* <br />fpr y..�.� . :....b •.n.�.. � �i'�+ `" <br />EH 23 046 (Revised 4/26/94) ,( � - — 1�0 !r -e4 Page 3 f d'1 <br />,- ;V -f u - . <br />