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E <br />n <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL 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 />r,I�(rlq REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # �G��j tVC441)r.2o9.S4T.�3ia <br />F <br />FACILITY NAMES <br />T'V i4 <br />PHONE # /�� G1�-,�t It <br />��T <br />A <br />C <br />ADDRESS(--Z� <br />I <br />L <br />CROSS STREET— <br />I <br />YOWNER/OPERATOR <br />-T <br />PHONE # <br />C <br />CONTRACTOR NAME 6pG---l�� <br />PHONE #Lo . S' -Cf j )o <br />N <br />CONTRACTOR ADDRESS o ' <br />CA LIC # 'Z 3 V <br />CLASS Q w <br />t� <br />T <br />R <br />INSURER <br />WORK.COMP.# 2 0Qp <br />A <br />C <br />FIRE DISTRICT . �^� <br />PERMIT # jjC&_te <br />V�( Thee <br />T <br />0 <br />LABORATORY NAME G(��/T p�( <br />COUNTY ,! �� <br />PHONE #e /1 C�r1_ j7/7* <br />�T <br />'T <br />R <br />/ <br />SAMPLING FIRM ( 4-4111-4Tot-4 <br />"1111111111111111111111111111 <br />TANK ID # <br />PHONE #29 b r l "7 5 <br />TANK SIZE CHEkl CAkS STORED CURRENTLY/PREVIOUSLY DAT UST INSTALLED <br />39- <br />T <br />39- <br />A <br />39- <br />.'�- <br />N <br />39- <br />t c _ <br />K <br />39- <br />39- <br />39- <br />1111111111 <br />II 111 1 111111111111111111111 11111111111 1111111 11111111111 <br />P <br />II111111—illlll 111111111 111 <br />I 1 1111 11111 <br />L <br />APPROVED <br />APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME <br />DATE <br />f <br />APPLICANT <br />11111111111111111111111111111111111111111111111111111111111111 t 1111111111111111111111111111111111111111111111111111111111111 <br />MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS <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." <br />CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE PERFORMAffE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFO NI <br />APPLICANT'S <br />SIGNATURE: <br />DATE <br />TITLE DATE <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />