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WI (� nQ( I Envi amental Health Department <br /> -C O U N T Y--- <br /> APPLICATION <br /> -_.__APPLICATION FOR UNDERGROUND STORAGE TANK <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 /> jk,REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT PHONE# <br /> FACILITY NAME 7-6i IR4)-Pr IPHONE# <br /> ADDRESS 1p2`1i vac i ,5-Zo <br /> CROSS STREET <br /> OWNER OPERATOR 7-E7evt, S Ivy/ &d.D I PHONE# .,-A4 -T1l-5Lj <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME L.Z, PHONE# <br /> CONTRACTOR ADDRESS 39067 N V�I .�M� CA LIC#77772-6 7 CLASSA $C <br /> INSURER lq� AP14f ;c-0ti SSS rq.«e_ WORKERCOMP# WC' C'$ aSQ <br /> FIRE DISTRICTS c vtY— PERMIT# 9 <br /> LABORATORY NAME 29'6W%tC COUNTY TPHONE# <br /> SAMPLING FIRM 'TrsV j4pfte i` PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRE ENT ND PAST DATE INSTALLED <br /> 39- <br /> 39- Z (� Dd r te411&fsgi <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: "I 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 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORK 'S TION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE TITLE wE� � .5 DATE �` l <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 /> 3of10 <br />