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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> i <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILIT ..,. MATT ON <br /> EPA SITE# PROJECT CONTACT MAtr c N Er2w n+>c PHONE# 9l6-q Z4-Q S7 9 <br /> a <br /> FACILITY NAME FO MEX LESCO - u NT PHONE# NA <br /> ADDRESS 2532 W, A5 WA/hTvn1 $71&� Stmt- vN SZ <br /> CROSS STREET UAV3 VE <br /> OWNER OPERATOR CA1201-`(N SA,tAUINETrl TXVY -T- I PHONE# 201-'/82-65Ci <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Of Fl FNviRt1NMtmwt- SCjVjt9,f, rA1C. PHONE# 6 t-303- 9503 6 <br /> CONTRACTOR ADDRESS 3LfOO jWA#WIt AXeAS F(Ct q GA 43W I CA LIC# I'S70 CLASS A <br /> INSURER AOPJ gt$Ki NtvY>Ati LE 3CytV1 GE j WF!5 (NG WORKER COMP# WC-It003571100 <br /> FIRE DISTRICT TDN F I(Lf- PERMIT# 11-3706 <br /> LABORATORY NAME 5VAIST4R- LAJ5..S COUNTY OUNAV PHONE# 3730-3ay-5525 gu.L <br /> SAMPLING FIRM -WEST NC. PHONE# - 9 S2$ PIATf <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- 9�x 9'x N"Q�JIU wRRcrny- WA v rwutlu <br /> 39- 0524 <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: .1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WOR R'S COM N ON S OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE ` TLE QCO j <br /> 1 +Ct Mlt"*5&lr _DATE G JAN/2V) <br /> 0 APPROVED PPR ED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CO Ull S BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM DATE <br /> ANY DEVIATIONS FROM THISPL ATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCI ORK. <br /> CONDITION§: <br /> EH 23 046 (Revised 8/1/11) 3 <br />