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pstkjll� <br />ENVIRONMENTAL HEALTH DIVISION o <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APR 2 3 1993 <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SU&k#i;u TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE Atwt <br />I ERVICLTH <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />ES <br />EPA SITE # I PROJECT CONTACT & TELEPHONE # <br />F FACILITY NAME San Joaquin County General Hoggpital <br />PHONE # <br />A <br />C ADDRESS 500 Hospital Rd., French Camp, CA <br />I <br />L CROSS STREET I-5 and French Camip Road, <br />I <br />T OWNER/OPERATOR PRONE # <br />Y Countv of San Joactuin <br />C CONTRACTOR NAME W. <br />M. Lyles Co. <br />PHONE #( 209 237-22 <br />0 <br />N CONTRACTOR ADDRESSFresno, <br />355 N. Thorne Avenue <br />CA <br />1766T <br />CA LIC # <br />CLASS _ <br />�� <br />R INSURER <br />WORK.COMP.# <br />A <br />C FIRE DISTRICT <br />-L c.-zw 0,4 C-0 <br />PERMIT # <br />T <br />0 LABORATORY NAME <br />R <br />to _ c r c r- �� <br />PHONE # <br />SAMPLING FIRM � �— PHONE # <br />1111111! 1111111111111 1111111 <br />AN ID # TANK ZE CHE CALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />,oT39• 79n ('a -n_1 ine 1G�0 �h <br />T 39- 75n r4acnI imn <br />A 39- <br />N 39- <br />K 39- <br />39- <br />1111 <br />P <br />L APP VE APPROVED WITH CONDITION(S) �_ DISAPPROVED <br />A �� !/ XE TTA ENT WITH CONDITIONS), <br />N PLAN REVIEWERS NAME DATE <br />11111111111111111111 1Yti�tlltf(i� 11111 <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. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <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: <br />"I CERTIFY THAT IN THE PERJDRMANCE-OFA THEMO�C FO�WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF ORNIA." J / � � <br />APPLICANT'S SIGNATUW f Xf /CZ— TITLE District Mncrr. DATE 4 <br />�/� 9' �'" �'�Y fli �. f/,�-2-� �' � �" y i�Z',1�'f/h/✓far,.�tt^-a �����" �, l <br />EH 23 046 (Rev^ 7/10/92) v Page 3 <br />