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�u. <br />' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />- <br />, NTAL HEALTH DIVISION a , <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERXlT <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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />V/ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE Atm L ppp 0+6 847q PROJECT CONTACT B TELEPHONE B I ;(„� (, _ NA(,-'-o.�J F'� ,l �G <br />F FACILITY NAME (s o(r -rDP %® PHONE E CT/ 10 - 37 3- t �$ <br />A <br />C ADDRESS Oso S, OL( I VF AvLl-5'rocie -n:A3 oa- 520S <br />I <br />L CROSS STREET M p, ) rJ g+° <br />I PHONE B <br />TOWNER/OPERATOR J ; t STOP M�� / ! N G • <br />Y Si 0 - <br />C CONTRACTOR NAME VjAL p/J PHONE # I 3 "13 <br />N CONTRACTOR ADDRESS Po B®� 1025 W. 5AC b Q5�'ll LIC x�,� 23g CLASS SCI �� ,J„ <br />R INSURER (TOC1(�(� IAIS(jNGE G4(LP WORK.CONP.x�WL4G2'7?J®..(0 <br />A PERMIT B I <br />C FIRE DISTRICT Cl-rV Cl-rOF S-roC•k:-rok) <br />To <br />0 LABORATORY NAME ^, 5 (,�s COUNTY 5q G(jiniLG-rj-kj PNONE M 1 J� G 3 8 — "7 <br />R PHONE 0510 - + 5395" <br />SAMPLING FIRM Ca,�?�IF,.JG� CLa5U9-6 <br />11111111111111111t111111111lII i <br />TANK ID X TANK SIZE `fes AL 5) CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- %I®- 1 10,000 c ip-e-A 1173 <br />T <br />A 39- <br />N 39- <br />K 39- <br />39- <br />' 1111 ! f <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME DATE <br />11111111!lttltl!lII1111111111111 111111!1111111lltllllllllllllllltll!!!l11111111111111111I11t1I1111lllltlllllllltlllltl!!llll <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 FORK 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 LIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PER CLQ 0 TM <br />WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALL OltHIA." <br />/t}{il( ®EVT MAWDATE Z8JUL ,le <br />APPLICANT'S SIGNATUR : TITLE <br />CONDITION(S): <br />1 <br />EN ,23 046 (Revised 7/10/96) <br />Page 3 <br />