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SAX JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATIO\ FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />CE <br />THE PERMIT FOR PERMANENT/TEMPORARYOR RE. OO�NOTBWRI07NEM2NTANY SHADED AREASIN PLACE OF ERINDDIICATE HAZARDOUS <br />TPESBELOW:STORAGE Ta1+K <br />EXPIRES 90 DAYS FROM THE APPROVAL_ CLOSURE IN PLACE <br />y REMOVAL TEMPORARY CLOSURE <br />707- 9f-5 KW4O <br />F <br />A <br />C <br />I <br />L <br />1 <br />T <br />Y <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />FACILITY NAME <br />v0N <br />PROJECT CONTACT & TELEPHONE # rfA%C% �tlaF�e F L-1 <br />ADDRESS <br />CROSS STREET pl ezoLi I <br />OWNER/OPERATOR _ N C-1 I F- G&, ;, —t e D <br />CONTRACTOR NAMEVrr CO 111 O(j <br />CA LIC # <br />CONTRACTOR ADDRESS F' %o ei 14(03 : 1.o tD 2 g5'�.4i <br />INSURER <br />FIRE DISTRICT WA'j(:jQ.LO® / iwtQ-a`®A <br />Iry MKO <br />LABORATORY NAME � COUNTY 0olA �e►NA1'' <br />SAMPLING FIRM <br />1{lltlltlltTANK tIDI <br />39- <br />T 39- <br />A 39° <br />N 39- <br />K 1 39- <br />39- <br />39-� _ <br />llltllttltltltlil <br />JA <br />PLAN REVIEWER'S <br />U <br />ttlI111111 TANK SIZE CHEMI <br />lO,OG'>Gi <br />APPROVED <br />PHONE # O oq <br />PHONE # Aon. list-IJ5 / <br />PHONE # -Zo cI . 54'1 _ 93 <br />S9 I CLASS A 4 JS C10, "AZ <br />WORK -comp..# W 9`1 S 1 <br />PERMIT # <br />PHONE # <br />415 371:5- 94 " 01600 <br />PHONE # <br />70 &o'?y <br />STORED CURRENTLY/PREVIOUSLY I DA <br />APPROVED WITH CONDITION(S) DISAPPROVED <br />EE NOITIONS BELOW AND/ORr'ON ATTAC,M/EN) 6,,,, � 3 <br />:^ 1 &r� 3 r bb DATE �L <br />(tlllltllllll{111111111lIIIItit1111it,uu,nnlltllilltl!{iltllltlllltltlltllllf11111t1111Nl01 REGULATIONSoFlttil <br />—�Illltttltlltl <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES A <br />IN <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SAN (CANT M ST PER PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT <br />THE PERFORMANCE OF THE WORK FOR WN <br />URE CE <br />SUBJECT TO WORKER'S COMPENSATION LAWS ONECAIIF WORK ORAWHICH HTTHIS PERMITHISIISS'UED , I�SHALLCTEMPLOY ING IPERSONS SUBJECT :RTIFIETOTWORKER'HE SW2 <br />°I CERTIFY THAT IN THE PERFORMANCE OF T <br />COMPENSATION LAWS OF CALIFORNIA." <br />(J JV�C-t DATE�/�7 <br />TITLE r �T• <br />APPLICANT'S SIGNATURE: <br />;7 <br />cr. <br />cl <br />EH 23 046 (Revised 9/11 9 <br />