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,av2UU3 2 52P Glacier Environmental No • 0371 P . 2 <br /> SAN JOAQUIN COUNTY PUSLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT17EMPOPARY 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. W0I0ATE PERMIT TYpE; <br /> 2 REMOVAL ❑ TEMPORARY CLOSURE ® CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA Sn0CAI-000zs-49b3 PROJECT CONTACT g, fn I I-e_ PHONEB4&2 r .3$ - 2gZ <br /> FACILI Y NAME "Z Ig Le,j w2 Z.z, - 3z2 Co Z PHONE# -0 30 9 9 r <br /> ADDRESS 7_3(oa L,Aj fir- 2.,� Tvacr C 9537(o <br /> CROSS STREET .1 eye f�o,� © <br /> 1.2WNEROPFERATOP -I- 1PHONE# <br /> CONTRACTOR INFORMATION <br /> CbNTRACTOR NAME 47 10.r i g., rr •4-o St/'✓w, 3 �_ PHONE# A<ZS 3S fit! <br /> CONTRACTOR ADDRESS 14LI(i to i�vx i t 2ac.� S�,f CA LIC# <br /> 1NSLNRER a s., In•*A Z WORKER COMP: La cj _ <br /> FIRE DISTRICTk- v PERMIT#, O <br /> t,ABORATORY NAME 5-4 A} . -e- COUNTY <br /> SAMPLING FIRM % b.` PHONE q I <br /> TANK INFORMATION <br /> TANK ID ar TANK SIZE TANK CONTENTS PRESENT& PAM DATE INSTALLED <br /> 39- S t s ao� Gc.s, a►.... �� I i49� <br /> 39- 1-7 <br /> 39- 0 vo <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.SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIPORNIP.• CONTRACTOR'S HIRING OR SUBCONTRACTING S4NATURE CERTIF E$ <br /> THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR W Hr_H THIS PEFUIrT IS ISSU60,I SHALL EMPLOY PM r.-ONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANT'S SIGNATURE TITLE_.' /t?5 1 cL ti DATE ZZ03 <br /> ®APPROVED APPROVED WITH CONDITION($) D DISAPPROVED <br /> E CONOmONS BELOW AND/OR ON ATTACHMRNl7 <br /> PLAN REVIEWER'S NAM DATE S� b3 <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR Y'0 COMMENCING WOR <br /> CONDITIONS: <br /> 1 EH 23 045(REVISED 08113!93) Pape 3 <br />