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SAN JOAQUIN EnvironEQF-e;- a0Fh <br /> ED <br /> -COUNTY-- - <br /> U( ( 0 �0 <br /> EN"FlONMENTAL HEALTH <br /> APPLICATION FOR UNDERGROUND STORAGE�MENT <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. <br /> INDICATE PERMIT TYPE: <br /> JW—REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT I PHONE# <br /> FACILITY NAME `7-�i EPc7 te^ -A -Z-C)637- IPHONE# <br /> ADDRESS Z,,l i vv- t cl,Zv <br /> CROSS STREET <br /> OWNER OPERATOR -IF�IeV4, PHONE# TtLI 77L-549 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME JX- PHONE# ��L1y <br /> CONTRACTOR ADDRESS 3957 A-) CA LIC#77lt2jo7 CLASSA $C <br /> INSURER AtP- AMS'%c$ti Z75. WORKER CO # W(L C.y$ a Sot l <br /> FIRE DISTRICT S PERMIT# <br /> LABORATORY NAME :7q COUNTY PHONE# -1 `O <br /> SAMPLING FIRM J PHONE# rgl- <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRE ENT ND PAST DATE INSTALLED <br /> 39- j /lJ X—V a7 vn <br /> 39— Z U LOX qt p 1a~'4ll4J <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,1 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: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL <br /> EMPLOY PERSONS SUBJECT TO WORK 'S M TION LAWS OF CALIFORNIA.' <br /> APPLICANT'S SIGNATURE TITLE [� `�S DATE <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 3 of 10 <br />