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SAN JOAQUIN COUNTY PUBLIC HEALTH S%VICES <br />ENVIRONMENTAL HEALTH DIVISION <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 />'eREMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />CONTRACTOR INFORMATION <br />FACILITY INFORMATION <br />EPA SITE # <br />PROJECT CONTACT t m 77, / r IPHONE# ,S L Y' 6S 3 <br />FACILITY NAME C t� <br />C PHONE # Cz y <br />ADDRESS <br />( o G <br />CROSS STREET <br />C I~ L C �- <br />OWNER OPERATOR <br />DC�'A(Z.f/N�-J>' O � Llfb1z l4 1''I164tlJ l' -t ftlTNj PHONE #C- W, -J 3 <br />CONTRACTOR INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />CONTRACTOR NAME SEMCO <br />JPHONE# <br />209-524-9653 <br />CONTRACTOR ADDRESS 1217 South 7th Street <br />CA LIC # 449864 <br />CLASSC 1 4 <br />INSURER State Fund Insurance ggppany <br />WORKER COMP# 007108-98 <br />39- <br />FIRE DISTRICT <br />PERMIT # <br />LABORATORY NAME i 7W� rV' _ (302 f}iU(LI f <br />SAMPLING FIRM /"I L o 13�iz <br />COUNTYf i�► L PHONE <br />A HAZ <br />ASB C57 <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT & PAST) DATE INSTALLED <br />39- jlq _ <br />I Z poo <br />39- <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 AGENTS 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: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECTTO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE ' TITLEC1C`^I� OW DATEr Y d"""' <br />❑ APPROVED <br />APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE -0-6 <br />ANY DEVIATIONS FROM THIS APPLICATION MUST E UBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS" <br />10119/98) <br />