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f` <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTrfEMPORARY 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 /> [REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#?'r QQb a4l Z I PROJECT CONTACT �'t n'1 C O r 11 E I( PHONE# Zo 9-7f b 'ZO/y <br /> FACILITY NAME 170.CI .L n)i A I - 0.r+- %- &CLS I PHONE# ZD cl-413- 1 17 7 <br /> ADDRESS I I P0.L 1 6 GVe- 2A 7 <br /> CROSS STREET o e m ox t e, L v1 e. <br /> OWNER OPERATOR /Cir0.. O of PHONE# ZOGI�1-{73'"II�I <br /> W+ W a++' -,aLmd Otanef 20 -951-IZo'7 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME VeLlued Fn i 4 eer; n PHONE# 2.0q-4(pY-2_0lq- <br /> CONTRACTOR ADDRESSto CA LIC# 1?— CLASS ff A Z <br /> INSURER •WORKER COMP, -113' Z.. <br /> FIRE DISTRICT 0-('4N SiD C- PERMIT# NI <br /> LABORATORY NAME CAI 01 ItA COUNTY n SOQ i PHONE# <br /> SAMPLING FIRM nv to n mtE n PHONE # O -100 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- 12 o o d <br /> j 39- 000 ml ad `' << <br /> 39- D " a <br /> l 39- 2 000 bic5ieL F4el ti <br /> 39- <br /> 39- <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: '1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 LAW CALIFORNIA.' <br /> Z <br /> APPLICANTS SIGNATURE TITLE DATE ✓" <br /> ❑ APPROVED 0,APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> 00 (SEE C DITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE 5�d] <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST RE EMITTED TO END F R APPROVAL PRIOR TO COMMENCI G WORK. <br /> CO D IONS: <br /> i <br /> EH 23 046(REVISED 08/13/99) Page 3 <br /> 1 <br />