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• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERWr <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 />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): - C -D V <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # G� DO�y 8�v <br />PROJECT CONTACT & TELEPHONE # ��� `v� 2� •T . ��� <br />F <br />FACILITY NAME �� <br />pn <br />rtJ <br />PHONE <br />�l <br />A <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET <br />— <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />l �+ <br />I" �G <br />C <br />CONTRACTOR NAME <br />-�a� <br />PHONE # <br />6 <br />N <br />CONTRACTOR ADDRESS O ' <br />Ro <br />a �A <br />CA LIC # 1'z 3 3 (P <br />CLASS w� <br />i <br />Tv� <br />R <br />INSURERS(I <br />WORK.COMP.# jjj�� <br />� SI '1 DOO <br />A <br />C <br />FIRE DISTRICT ��� '� <br />PERMIT # Ot&_je <br />T <br />0 <br />-- <br />LABORATORY NAME G�?/tp�J <br />COUNTY ��� <br />PHONE # 2 c� -y <br />i7GJ5 <br />R <br />SAMPLING FIRM �j( �i�to� <br />/�'., <br />PHONE # �94- k7e;-r <br />Illlllllllilllllllllllllllll(I <br />TANK D # <br />TANK SIZE CNE ICA S STORED CURRENTLY/PREVIOUSLY DATE LIST INSTALLED <br />39-� <br />6� <br />T 39- <br />A 39- T� <br />N 39- <br />- <br />K 39- <br />39- <br />39- <br />111111111111111111111111111111 <br />P <br />L APPROVED <br />7APPROVEDWITH CONDITIONS) DISAPPROVED <br />A <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME % <br />- DATE `7 <br />11111111111111111111111 <br />illillllllllllllll(II11111111111111111111111111111111111111111111111111111111111111111111111111111111 <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. <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />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 PERFORMA CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFO NI " <br />SIGNATURE: <br />TITLE �ll DATE 9-0"9y <br />APPLICANT'S <br />CONDITION(S): - C -D V <br />EH 23 046 (Revised 9/11/96) Page 3 <br />