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SAN �QUIN COUNTY PUBLIC HEALT _RVICES <br />NVIRONMENTAL HEALTH DIVITIZ- <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />10/11110 <br />0 TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />FACILITY INFORMATION <br />EPA SITE #C-.40 <br />9.61460Z.!'.3� PROJECT CONTA VZ. 17 PHONE#570 (/� . 83 o <br />FACILITYNAME <br />FLL - J LO <br />p GGC PHONE# <br />ADDRESS <br />O CTO <br />IAO <br />CROSS STREETf-K <br />M ( <br />WORKER COMP#W4d JZQ2,gZ7.001"V02.3 <br />OWNER OPERATOR STIRr/OAI /S <br />CL ®5Ep PHONE # <br />TANK INFORMATION <br />CONTRACTOR INFORMATION <br />TANK SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED <br />CONTRACTOR NAME <br />R O / SO 11?, 'C l C <br />39- .4o S <br />PHONE # Sl® - (pJ - S 3 90 <br />CONTRACTOR ADDRESS <br />2- 600 W14 L/ S . •" <br />[ D I CA LIC # <br />6 Z Z 20 U cLAssAR cQ <br />INSURER Gid <br />(/Co, <br />WORKER COMP#W4d JZQ2,gZ7.001"V02.3 <br />FIRE DISTRICT ZODI <br />FIREp j <br />PERMIT # <br />LABORATORY NAME <br />LI O/ G L <br />COUNTY S /7.474F4 <br />PHONE # gj,0 - Z 2 Z <br />SAMPLING FIRM cdaaaiid <br />c&moA-,~A1rA4PHONE <br /># - <br />- Q oo <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED <br />39- " 3-3 o (7) <br />IL 000 97 0v1-&gDCD CwAS <br />39- .4o S <br />i f 000 9Z U-Vl-,f De <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE TITLE ® "oWr EXO.E/V/Z DATED . ZO - s <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 />EH 23 046 (REVISED 08/13/991 <br />Pane 3 <br />