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rJ�—LU-1777 coo•.� i i rKU+'1 I U 14252518'lH� N.bl� <br /> SAN JOAC N COUNTY PUBLIC HEALTH SEE CES <br /> EN,IRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> ,7HS PERMIT"OR PERMANENTfTE?gPOPARY CLOSURE ORASANOONMENT IN PtAC,-:OF LA�lDERGROUND <br /> 5 ORAGE TA>�K(S) ECP(RES 90 DAYS FROM- APPR -AL OAT-- �NOT�MRfTc IN At t'(��� �DOUS SUBSTANC`S <br /> AREAS. LNOICATE PERmrr TYPE_ <br /> ,X,R>~MOVAL ORARY CLOSURE ❑ CLOSURE IN PLACE <br /> ACIL]TY INFORMATION <br /> *PA k I PROJECT CONTACT / � �K Pyp{� 4 Z /-< Z Z zS I 7 / PHONE d Zc�T <br /> mtTR \ <br /> OWNER.OPE.-�ATOR Lr�n/ 1.— <br /> CONTRACTOR <br /> L/cZ GCS I PrtONE zt 7 <br /> CONTRACTOR INFO pN <br /> cT012 NAME 7 c 3ctcLl�Q PHONE# <br /> ONT R.4CT OI§ADDR <br /> I CALICS ( c1_Ass <br /> I conaPrx <br /> PRE DI <br /> PERI # <br /> OR NAME ; cS UU/r4 Ary CGUNTYPHONE <br /> PHONE R <br /> PUtVG FIFSA x <br /> i <br /> TANK INFORMATION <br /> TANK ID# TANK SIZ- TANK CONTENTS lPf2ESENT& P <br /> '7 ! DATE INSTALLED <br /> 39-- ' <br /> 2v /Z1I3 <br /> 39- Z jy <br /> i •7 r�/E S "JLi �C= � <br /> 39- ; 8/ <br /> 39- I <br /> 39- <br /> REGUL Ti MU 4T PERFORM ALL WORKCMN y "TH SAN JOAQUIN COUHIY ORoR44NCZS,5,,-ATE LAWS.FEDERAL LAWS,ALIO RULES AN()REGIJLA770NS QF SAN �OaQcnN CQUNTY PUBLIC HEALTH SERVtC£S. OWNER 0"UC.'> ?JSED AGE'4T-s SIGNATURE CER-nFlES THE FOILOWtNG. -1 <br /> CERTIFY THAT iN THE PERFORL"AtCE OF THE WORK FOR WHICH TRIS PERMIT!S ISSUED,I SHA t NOT ISVIPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SLR tECT TO VVORKIIt'S COMPB<SATK}N UWS OF CAL]FORNlA' CONiTtACTORS IfAtlNG OR SCJBCONTRAC'ING SiGNATZlRE CERTIFIES <br /> THE FOU. : -1 CSn-IFY THAT RtitANCE Tli>+WORK FOR Wilk:H TIi1$PFJAtIT IS G ORS 1 <br /> WORKL-M CO PENSAT16N!A CAI t�iril+t- SIit LL EMFx-Oy PERSONS SUBJE,•-r TO <br /> I <br /> APPLICANT'S IGNA `•O <br /> i I <br /> ❑-APiPROVED Cl APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SE—COND(f10NS aCLO WANO/OR QNATTACHmENT) <br /> PtAN F?EVIEINE.R'S NAME <br /> DATE <br /> ANY DEYIATTON5 FRO&t-THIS APPLICATION JALIS-4 SE SUBMI7-TED TO E�0 FCR APPROVAL PMOR EG CJMIyL!Nt:NG WORK. <br /> CONDITIONS- <br /> I <br /> I <br /> :f 23 046(1ZEV'1ScO 14/14/99) Pa,e 3 <br /> I <br /> I <br />