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• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />EIWIRONMENTAL 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 />1/ oaMnvai TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />CONDITIONS): CONDITION(S): v 14-4 <br />EH 23 046 (Revised 7/10/96) Page 3 <br />EPA SITE # 001 3�J+Q <br />PROJECT CONTACT & TELEPHONE <br />F <br />FACILITY NAME n`�� 0',�.� 1 o <br />PHONE v`� 3 3 _ 3 23 <br />C <br />ADDRESS z ©I W. - 7-- .NMN C• LpAi Glc �► ? —. <br />1 <br />L <br />CROSS STREET Ni tti1 ! , <br />I <br />OWNER/OPERATOR ?j fLS:- (�—, n gF r 1/_7Z <br />1�"-Ti`J(y,jtr"1 `-i <br />PHONE <br />-33C, <br />Y <br />C <br />CONTRACTOR NAME Vo. L�rj ? ING� (/'JC- <br />PHONE # (j(,o �j-7'Z-1 �E58 <br />N <br />CONTRACTOR ADDRESS PC 60)< j Z257 w, St4C,,, �`�,��+� 4 <br />CA LIC (1 ; L3 b <br />CLASS A"f $ HAZ <br />T <br />R <br />WORK. COMP. WNLT 434,C)2 - <br />INSURER <br />C <br />FIRE DISTRICT LoD1 ��* �= C'L� )3�3- 10 35 PERMIT ". <br />T <br />0 <br />J <br />LABORATORY NAME COUNTY SAC jZtZMJwr PHONE # <br />R <br />SAMPLING FIRM LSH T r1 / �.1 (- l�!! f�-cst*5t� C i PHONE <br />TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />Q Nj , n/NzOL-t <br />39- - <br />Al <br />A <br />39- — o - ,t1c�c� <br />N <br />39- <br />K <br />39- <br />9 -39- <br />1 <br />39- <br />39- <br />39- <br />P <br />P <br />L <br />APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N� <br />�- /7`!-4� DATE <br />PLAN REVIEWER'S NAME_ <br />1u111111111111111111111111111111111n1111111111u11u1uu11111n11111111111111u1111111111111111111uui1111n1111111111111, <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <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:1 <br />"I THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />CERTIFY THAT IN <br />COMPENSATION LAWS OF CALIFORNIA." <br />/ <br />Pr-6S,jol�iitr DATE /'34d"/ <br />APPLICANT'S SIGNATURE: TITLE <br />CONDITIONS): CONDITION(S): v 14-4 <br />EH 23 046 (Revised 7/10/96) Page 3 <br />