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f M1 <br />SAN JOAQ .. COUNTY PUBLIC HEALTH SER*ES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORA E TANK(S) EXPIRES 40 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />EMOVAL *TEMPORARY CLOSURE CLOSURE IN PLACE <br />'O� <br />TANK INFORMATION <br />FACILITY INFORMATION <br />EPA SITE # C C DO. 1059140 <br />PROJECT CONTACT Ed CCt7 777 ::77 PHONE# Z04i -239 - +- 41 <br />FACILITY NAME cj U P 51-0 F' arKet PHONE # 209, - 25q - 4 V75- <br />75ADDRESS <br />ADDRESS1-90 r), rnc1 1 n <br />--TC M A n-�'ec-ca a, �i 53 ala <br />CROSS STREET j''\orT H S% <br />44 QL-) CLASS <br />OWNE PERATOR CQ r � o26- <br />PHONE # ZCq <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />CONTRACTOR NAME <br />G'a5 Re iq"I(�rs <br />PHONE # -4 33 <br />CONTRACTOR ADDRESSQS2 <br />CA LIC # <br />44 QL-) CLASS <br />INSURER <br />'Ph(X373?4341 WORKER COMP# ,'Z <br />- pp -?A,- <br />FiRE pF <br />(HQn-F �_- c c, i PERMIT # <br />LABORATORY NAME <br />COUNTY <br />PHONE # .ZD 1.9LIA <br />SAMPLING FIRM AM <br />PHONE R <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- Icm <br />G'a5 Re iq"I(�rs <br />39- <br />coo ,A 5 Ml' - f0 -a e_ + l <br />39- 3�� <br />8, o0o Ga S Sw eT <br />39- <br />39- <br />1139 - <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE'MTH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, i 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 FCR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br />APPLICANT'S SIGNATURE TITLE T'/L<J�_.l.�,IGtu�l DATE <br />❑ APPROVED t'APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />QL;2� <br />�7 (SEE CONDITICNS BELOW AND/ORON ATTACHMENT) <br />(/lamPLAN REVIEWER'S NAMEDATge/2- <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVA� PRIOR TO COMMENCING WORK. <br />A, CONDITIONS: <br />lon <br />