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<br /> <br /> <br />3 of 10 <br /> <br />Environmental Health Department <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />CLOSURE PERMIT <br /> <br /> <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 /> <br /> REMOVAL  TEMPORARY CLOSURE  CLOSURE IN PLACE <br />FACILITY INFORMATION <br />EPA SITE # PROJECT CONTACT PHONE# <br />FACILITY NAME PHONE # <br />ADDRESS <br />CROSS STREET <br />OWNER OPERATOR PHONE # <br /> <br />CONTRACTOR INFORMATION <br />CONTRACTOR NAME PHONE # <br />CONTRACTOR ADDRESS CA LIC # CLASS <br />INSURER WORKER COMP# <br />FIRE DISTRICT PERMIT # <br />LABORATORY NAME COUNTY PHONE # <br />SAMPLING FIRM PHONE # <br /> <br />TANK INFORMATION <br />TANK ID # TANK SIZE TANK CONTENTS (PRESENT AND PAST) DATE INSTALLED <br />39- <br />39- <br />39- <br />39- <br />39- <br />39- <br /> <br /> <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 WORKER’S COMPENSATION LAWS OF CALIFORNIA.” <br /> <br /> <br />APPLICANT’S SIGNATURE _____________________________________ TITLE ________________________________DATE_____________ <br /> <br /> <br /> APPROVED  APPROVED WITH CONDITION(S)  DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> <br />PLAN REVIEWER’S NAME_______________________________________ DATE____________ <br /> <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />_____________________________________________________________________________ <br />_____________________________________________________________________________