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DEC. -16' 96 (MON) 17:20 UNOCAL C,_ NORTH RE TEL 510 2' X09 P. 009 <br /> FRGM 1 - <br /> 1996.12-16 1617 #955 P.04/06 <br /> ENVIRONMENTAL NSALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK,CLDSURE PERMIT <br /> APPLICATION FOR PERRAREYTR¢MPORANr CLOSURE OR ARAHDDNMEYT IN FLACE OF WNDBROROIIyD HAZARDOUS SUBSTANCE aTORAO[ TANK <br /> THIS PERMIT EXPIRES 9G DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANT 9YAD[V AREAS, INDIMAT'E PERMIT.TTPE BELOW: <br /> REMOVAL _ TEMPOPMT CLOSURE CLOMINE.IN PLACE <br /> PADOR153 <br /> ` PROJ¢CT CONTACT L TELEPHONE Y ^ <br /> F 11=0rMPJ nOc,� F '� pt-u, PHONE Y .NIA <br /> A <br /> C1 C2n+rk I Ave LPHONE Y <br /> Tfl J oter. r Sl0-V-3- y311 <br /> C CONTRACTOR MANE <br /> 0 <br /> N CONTRACTOR ADDRESS1 <br /> T CA LIC Y T 2_ GLASS <br /> / <br /> R INSURER !O <br /> A I= 12can"rIffl- 02 -0 <br /> t FINE DIiTRIR �+ �} Q TI'F PERMIT 0 <br /> Q IASORATWr xAME 5 , PHONEY 510-rjQ �- �oaa <br /> SAMPLING FIRM r"tIIlpry y,AV U/ZU -A1G PHONE R Q - ?:S-v D <br /> l 11 llllllllltttll I�I I�IIII II11 <br /> :INR ID TANK 7i2 C/NEMICALi [TD CUR TT/P0.EV1 al] DATE LIST IY ALLE13 <br /> T 39• j D 49QSw/.L / L�ee/iJ �d �1 _� <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> rnr <br /> P <br /> L _APPpOV® APPAMED WITH CONDITIONVED <br /> S] _ DISAPPRO <br /> A (EEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> III[]IIIIIIIII II1I11 Itlll <br /> 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOIIN CORNTT ORDINANCES, KTATE LAWS, AND RULES AND pEOIUTIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AOENTIS SIGNATURE CERTIFIES THE POLLOWINGi "I CERTIFY THAT IN <br /> THE PERFORMANCE DF THE WORK FOR WHICH THIS PLR91T IS TSSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO EEWKE <br /> VAJECT TO WORKERS MNPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER THE POLLOUING, <br /> "I CERTtFT THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOT PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF LnLIFORNIA-u <br /> APPLLCANT-S SIGNATULEi 20,- LC - '+ TTTL9S2. CNV. IS?ebLOG%5VATS <br /> ¢H 23 OA6 (ReVMsed L�/9L) .. Pelle 3 <br />