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YJG-10-1777 uu•.�, , r-nu,', I u 14252518782 1'.02 <br /> SAN .JOA^'JIN COUNTY PUBLIC HEALTH S 'VICES <br /> • L . /IRONMENTAL HEALTH D1VISfOr, ' <br /> q� APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PEf;M(T OR PE-14MANENTITEWORARY CLOSURE ORASANDONMENT W PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGc T K(S)EXOOES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br /> AR -MOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA Srr` it PROJECT CONTACT &27 Z <br /> FACILITY E & _ P14cx�E <br /> ADDRESS <br /> CROSS!STRE�ET <br /> OWNER;OPErtATOft Lffn/ i �i tZ D C PHONE <br /> CONTRACTOR INFO Tl <br /> CONTRACTo NAME. Tc 3t��Cdr�i) pt O,c =a <br /> CONTRALTO ES <br /> ADDRS cA LIC a CL0.SS 8 /f <br /> INSURER , COMPt� <br /> FIRE DISTRIC e j <br /> LASORAtTOft NAME ! cS QUU..q �rV �`T/ PHONE A= <br /> SAMPUIVG FICA VNE <br /> i TANK RMATION <br /> TANK D# TANK SQE T NTENTS(Pf2ESENT Z PAS-0 DATE INSTALLED <br /> 39— 2 �v �- <br /> 39— Z � <br /> 39— ' / z _ <br /> 39-- <br /> 39— i <br /> 39— i <br /> APPLICANT MUIT PERFQRM ALL WORK IN ACCOOMANCE WTH SM JOAQUIN COUNTY ORDR4ANCES.STA3 E LAWS.FEDERAL ,u10 RULES ANO <br /> REGULATIONS 9F SAN*OAQUIN COUNTY PUBLIC HEV.TH SMWICES, OWNER OR LIC ED AGENT- S SIGNATURE DEKA LAWS,THE NO RuL TNG: •T <br /> CERTIFY THAT IN THE PERFORMANCE OF TT{E,%IORK FOR WHICH THIS PERMIT IS ISSUM,1 SHALL NOT er4Pi 0Y ANY PERSON W SUCH A MANNER AS <br /> TO SECO161E SU ECT Tp YVORK IrS COMPU3 EATION LAWS OF CALIFORNIA•' CONTRACTOR'S MUNG OR SUBCONTRACTING SIGNATURE CEPTIFiES <br /> WORKER'S C <br /> THE ER'S CO0 7 CERTIFY THAT CAUFORNtA.'O� R THE WORK FOR WHK3AI.L 1 THIS PEjoi IS ISSUED.I STTEMPLOY PERSONS SUgj=�T To <br /> PENSATIOl/LA <br /> APPUCANT'S IC-"NA / <br /> TITLE C DATE <br /> I <br /> ❑ APPROVED-. C3 APPROVED WITH CONDITION(S) 7DISAD <br /> (SEE CONINT;ONS BELOW AND/aR ON ATTA,CMieI•n <br /> PLAN Ri�/1 'S NAME <br /> ANY DEVIATIONS FRO1KTHIS APPLI ATION LlUST BE SUBMITTm TO E fD FOR APPROVAL.PRIOR <br /> CONDITIONS_ <br /> =il 23 046(REVISED loll 9138) page 3 <br /> i <br />