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Now <br />PAYMENT <br />RECEIVED <br />JUN 181998 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISIONSAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE ENTAL HEALTH DIVISION <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />x REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br />of excavation. <br />EH 23 046 (Revised 7/10/96) Page 3��� <br />EPA SITE # lAf,0 0 ( jq 0850PROJECT <br />CONTACT a TELEPHONE # F(C{� 4C AMI � Com) SZy �(6S3 <br />F <br />FACILITY NAME (Z( H t -o e �el.kooi �lSt VlC% <br />PHONE L!q <br />A <br />C <br />ADDRESS L�•f C.�C,IOL <br />I <br />L <br />CROSS STREET <br />1Ne { <br />I <br />T <br />Y <br />OWNER/OPERATOR <br />uKl <br />PHONE # <br />204 �G�7 Z( 271 <br />Q1 tPv� Q� iL�fJ'J l (O�St�tf.� <br />C <br />CONTRACTOR NAME Jra, jW <br />PHONE # ( 209) 524-9653 <br />0 <br />N <br />CONTRACTOR ADDRESS 1217 S. 7th St. Modesto, CA 95351 <br />CA LIC # 449864 <br />CLASS A,B,C61/D40 <br />T <br />R <br />INSURER CalcoW Insurance Camany <br />WORK.COMP.# W964137662 <br />A <br />C <br />FIRE DISTRICT (I.I ( �� <br />PERMIT # <br />M2 <br />i <br />T <br />0 <br />LABORATORY NAME Geoanalytical I.ab <br />CWNTY Stanislaus <br />PHONE # (209) 572-0900 <br />R <br />SAMPLING FIRM Geoanalytical Lab PHONE # (209) 572-0900 <br />TANK f0 TANK SIy� CyEMI CAIS STORED CURRENTLY/PREVIOUSLY GATTEUS INSTALLED <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />(((���� <br />P ��`/// <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (EE CONDITIONS BBELOW AND/OR ON ATTACHMENT) <br />N PLAN REVIEWER'S NAME- SAW AiQ/ DATE <br />(��(���((111IIIillllllllllllllll111������(1111111111111111����(IIIIillI111111111111111111111111111111111111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK Ir ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR RICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSAT[ LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFOR NCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORN A." <br />r <br />/ <br />C// <br />�� • DATE <br />APPLICANT'S SIGNATURE: TITLE <br />CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br />of excavation. <br />EH 23 046 (Revised 7/10/96) Page 3��� <br />