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SAN JQAQUIN COUNTY PUBLIC HEALTHS VICES <br /> VIRONMENTAL HEALTH DIVISI <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 /> Dq REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# C OOQ[ PROJECT CONTACT T,, CgtjI4& PHONE# Z QQtA <br /> FACILITY NAME G PHONE# 2oq- y <br /> ADDRESS S <br /> CROSS STREET G• E, £ bi ' S} £t <br /> OWNER OPERATOR P G PHONE#$ .Y7 •SS <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME AjvjAjNLCjp -In(-. PHONE# ZO -/co <br /> CONTRACTOR ADDRESS tiog g tJ. LV;ISQt-\ WA\Y I CA LIC# ao U CLASS <br /> INSURER Acggo - DEelt Y P%EtvToA If Oss , WORKERCOMP# 31 <br /> FIRE DISTRICT C j j_ $T C ti E PERMIT# <br /> LABORATORY NAME )&a PjvA/Zd;Cqj COUNTY Af g;,4 M 0 PHONE# ,Q - y(r - Y O <br /> SAMPLING FIRM al )4 pI PHONE # ® •0 <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 12,1 _ w i s <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: '1 <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,1 SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS F CALIFORNIA.' <br /> APPLICANTS SIGNATURE T1TLE� • T l�P IQ S DATE <br /> ❑ APPROVED PPROVED 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 PPI IOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />