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`. ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL. DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> i <br /> EPA SITE ' v PROJECT CONTACT.& TELEPHONE # , <br /> C.�C UovC�ZSZ meq. _ qZ1 49110 <br /> F FACILITY HAMS 7- EL G\/GN Sou-�I�cA> �� Gond. ] PHONE # Zo9- q,-1-7-/_-701 <br /> I`. A � • `T C� I <br /> C ADDRESS Q 10 THofZNTot.� Rn. <br /> L CROSS STREET L/�r J � �AL.Lr3M��J <br /> I� [ +j <br /> T OWNER�)PERATOR PHONE # <br /> Y S oUj-kj AND CvszP. J t F� X111 u sdf,J Z o9 - zb 1— �7 d 1 <br /> C CONTRACTOR NAMlE7-_j'rZ1A8 G LF, ) AC . b�' S A CT,o . PHONE # 4 16- 4 Z l_) 9 9 o <br /> O <br /> N CONTRACTOR ADDRESS�O. ? O 9 i n r.,�.D. CAL., CA LIG # Q 3 L O CLASS A <br /> T l 1 1 !`!\.3 V J <br /> R INSURERJa M N 0.l6fWkSoj4�j CG. .� 1' (� WORK.COMP-#,WNOSo19B1o� <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> 0 <br /> � o <br /> Cti ST ckTox <br /> T <br /> 0 LABORATORY NAME PONE fl <br /> R 91 to- & <br /> _ <br /> SAMPLING FIRM - L PHONE # <br /> 9 ! � - Co35 39(02 <br /> IIIII1fIIIIlIf1IIIliiiiili I <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/P EVLOUSLY DATE ST NSTALLED <br /> 39- J&-g coo GAS ����. �� <br /> T 39-'ebLr,-f1Q <br /> A 39-L'RffQ-r13 PWI l <br /> N 39- <br /> K 39- <br /> 39-1 <br /> 39- <br /> L <br /> I I I <br /> I I III11I1IIlIl1IIlIIIIIII flillllll111IIf11 <br /> II f1f II 11I fl tl Itl 1I I1I 1 III II 11I II II ill 11 Ilt <br /> P <br /> L APPROVED APPROVED WITH_;CONOITION(S) DISAPPROVED <br /> A ( ACHMENT WITH CONDITIONS) i y <br /> N PLAN REVIEWERS NAME v r f G DATE [/ Iw I�j <br /> III if I II II III If If 1111111111111111111111 11111 If I lI 111 II I1 I1l II 111 I111I II III I1 Il I1 t 1111111111 II II III II I l I1 I111'I III II II 111 I1 it t <br /> APPLICANT MUST PERFORM ALL. WORK IN ACCORDANCE WITH SAH 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 PERFORMANCE OF THE WORK FOR WHICH THIS PER MIT 'IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA-" <br /> APPLICANT'S SIGNATURE: .TITLE `c_ hmes DATE <br /> EH 23 046 (Rev 2/8/91? ft Page 3 <br /> 4 <br />