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05, 10:'99 09: 18 F.-�-T 425 251 8782 BARGH3USEN 2003 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> c` ENVIRONMENTAL HEALTH DIVISION <br /> I APPLICA T NON FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> TT'.IS Fr_RMIT F111 OR PEFtAAA1`tE. CLOSURE OR ABANDONMENT IN PLACE OF LMERGROUND HAZARDOUS SU6STAN0E3 <br /> SORAGE TANK(s)2(P�RES 90 DAYS F ROAA THE APPROVAL OATS DO NOT MZITE IN AMY SHADED AREAS. W01CAM PERMrr TYPE <br /> I !I <br /> )!.REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> ! FACILITY INFORMATION <br /> I EPA SCM it PRO.ECTCONTACT �/ ,E'i 2,� mjoc 4 ?F1-l02Z Z. <br /> PACRJrY NAlk A' , I PHONE <br /> ADORESS I — E. - ylmw4i N r kl4 Y -_5%mac Tei./ Ga 5'57ZO <br /> { CROSS'STRe—i=Tsi— <br /> O+n44M.CPE TOR L,41,/ I PHONE# 7 &70_r <br /> CONTRACTOR INFORMATION <br /> COt4TRACTOR NAME . . F c'T?1 E/Z AZY4,✓ //yC, ► PNOt >< 9 Z S- 5S/- 7944 <br /> COriTRACTO aOOR>=SS -17 S, -jwzW `"1c.4 I CA uC a Z207CLASS g /f <br /> Ir=JRER mAr5 v sNtu�nn�cc lr>�QfCALS I W4�x>�C> tPm w�QgBoas��/ <br /> FIRE DISTRICT G h P rE 2LcFT# <br /> LABOR.WOR'i NAIAE ! Ye-a4101,4 AAry YT/ COUNTY PHONE R <br /> MAut;iG FtFtM PiiCNE tk <br /> i TANK INFORMATION <br /> TANK 10 t TANK 5tZ-= TANK CONTF-NTS(PRESENT& PAST) ! DATE WSTALLED <br /> 39- ! I . Z 62�0 <br /> 39- ; Z I /Z I� E S !L <br /> 39- <br /> 39- i <br /> APPUCA.ItT MU4T KRFQRN ALL WORK IN AccoFtamcZ11 T SW X ACLUN COUNTY OfW~Crs $TATE(AWS.l WeUL(AWS ANO RULES ANO <br /> REG,k" ONS PF SAH JOAQUW COVKrf PUBUC WEALTH S>OLVICM OWNER OR UCOASM AGefr,S1 NAMJW_CF=SeS THE FOILOwu4c.: 't <br /> c0awY THAT 44 THE AERFOIwANC£OF 774E vMK FOR NMtCH INNS PERT IS 155< .I%1ALL NOT BAPLDY ANY P£R.50N W StC A MAN�AS <br /> To SecomE susiscr T16 am CaM4815ATM LAMG OF CALWORHN• C0M7RA[-,0RS HWUNGs OR SLTC0KTRACTNQ SUP(A URE CaltYWIES <br /> THE FOLLOVW4q: 1 CERIVY THAg FLA/�KE THE Y40RK FOR WHICH 7145 PF3amT t5 tMim.I SH jzL evj.OY PF]i50NS St381EGT To <br /> wORKEWS CIPENSATIbN LAAPPUCAifrS 11lGNA er( <br /> TFTL /Q�G`3d�/TfA� �c OA <br /> I <br /> 0-APPROVED' ❑ APPROVED NTH CONDMON(S) Q DISAPPROVED <br /> =Cok=CmS aMCWNMt CR 0"ATIAC WJE'4 j <br /> PIAN R`cV1EWE=23 NAME /Jr) r_ CATE!I <br /> ANY DEbLATTONS FROIKTMS APPLICATION,MUST BE SUBMtI-TED-,o EfM FOR APPROVAL PRIOR TO CJM e4aNG WORK. <br /> CONDITIONS: <br /> jj <br /> � I <br /> f F / <br /> t Z3 046(REV)SED ,oil 9,v8) Pat�je 3 <br /> C, vv t-, locpq17 <br /> ,� <br /> �� <br />