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j0 A �'�9 RECEIVED Evivlk'fA (14Tlental Health Despartaient <br /> cou l\lTY <br /> SEP 10 2019 <br /> ENVIRONMENTAL HEALTH <br /> APPLICATIOWPbRTONDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS <br /> SUBSTANCES STORAGE TANK(S ) EXPIRES 180 DAYS FROM THE APPROVAL DATE . DO NOT WRITE IN ANY SHADED AREAS . <br /> INDICATE PERMIT TYPE : <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE 69 1 PROJECTCONTACT " el 5w 4Z <br /> FACILITY NAME e OiUy� 7lYI PHONE # ZO 9 `f •- <br /> ADDRESS 7 &,L466- (/� 70i✓ / L <br /> CROSS STREET C /1/ 61 <br /> OWNER OPERATOR L0cord y aG // 7 1 PHONE # lo 49 dt-7 k02 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME � /!7 / �;zt2 e/e � CPHONE # 2 <br /> CONTRACTOR ADDRESS ' 7 A • / %�/JlJ/s1J OR/� CA LIC # C CLASS ./A.01 <br /> ,H�Z �/ <br /> INSURER 2/6/y% WORKER COMP# S7<972,o4�avLIQ <br /> FIRE DISTRICT PERMIT # <br /> LABORATORY NAME PHONE_Z4 IL444 <br /> J ` 2 #-oleo <br /> SAMPLING FIRM PHONE # 2.09p d <br /> TANK INFORMATION <br /> TANK ID # TANK SIZE TANK CONTENT , PRESENT AND PAST DATE INSTALLED <br /> 39- OC920' V3 0f/ <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING : " I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKE SMPE ION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE r TITLEi2C F?F4 < (ME (C DATE <br /> ❑ APPROVED 0 APP OVED WITH CONDITION (S ) ❑ DISAW! ROV.1( CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME 1eW I , " DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS : <br /> S'4 <br />