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• <br />• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />y REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />Oslo- <br />ice-- <br />c� <br />EH 23 046 (Revised 9/11/96) Page 3 <br />T <br />EPA SITE #A -Vo goo� 1� <br />PROJECT CONTACT & TELEPHONE # <br />�� T I <br />F <br />FACILITY NAME�j'G <br />PHONE #� <br />14- <br />C <br />I <br />ADDRESS iJ �I��h J� 4,-T0G G� <br />✓�� <br />GA �W <br />L <br />CROSS STREET �I V <br />YOWNER/OPERATOR <br />� <br />PHONE #L-1 <br />C <br />CONTRACTOR NAMEK\/MF-Rj5F-j/ Aeojji�vH <br />PHONE # I /;* <br />0 <br />`� <br />N <br />T <br />��/� <br />CONTRACTOR ADDRESS 112�'�- Q� 1 �p4*C,09 CA LIC # <br />201 <br />CLASSA �I G-jD G <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT G� �� ��GF"�N /kEP <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME) �� <br />COUNTY g:44- ?W j0l�A <br />PHONE # 2 <br />R <br />_iV <br />SAMPLING FIRM t1111111 -fel 14 �ww CO <br />PHONE # l� 3 Qr e71 IO <br />I <br />111111111111111111 1II <br />TANK D TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />III11111111111111111111 IIII III illlllllllllllLllllllll11111 1 11 1111111111 <br />I 11111111 1111111111 II1111111111111111111 <br />L <br />_ APPROVED f'APPROVED WITH CONDITIONS) <br />DISAPPROVED <br />A <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />Nfl�il�4�--� <br />0 <br />PLAN REVIEWER'S NAME <br />Q <br />_r( <br />DATE <br />11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />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 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CAL NIA." <br />APPLICANT'S <br />SIGNATURE: TITLE <br />W G DATE 4 <br />CONDITION(S): <br />Oslo- <br />ice-- <br />c� <br />EH 23 046 (Revised 9/11/96) Page 3 <br />T <br />