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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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 /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE 7 <br /> EPA SITE * C/fjy;�()604MI PROJECT CONTACT d TELEPHONE 1 KR„1h M <br /> F FACILITY NAME A4 -Ar-r11 11 f1 I PHONE # Loq- 13 1 - <br /> C ADDRESS 3133 N. Ad Art Dead 57'0clOo <br /> 1 <br /> L CAO55 STREET C VI HO K+i R!a <br /> I <br /> T DOWNER/OPERATOR Av'-r '�v �q Lt Uor-k0f ber9Pv PHONE 'J Q/O <br /> Y /1Q n 7L04'q � l - o5 / <br /> C CONTRACTOR NAME A q vct li (4 •O rE N v; roti m o vi't(t l PHONE o zoq • 4 6 7- 1 00 6 <br /> 0 <br /> N CONTRACTOR ADDRESS 4005- N. Wj 1pa&I Wq y CA LIC 1 640227 CLASS <br /> T 1 e l <br /> AINSURER A CC)rd " �Aq l+� 9� 5-t IOI'1 � '1 SS kio f I WORK.COMP.1 131 I', 7 � <br /> C I FIRE DISTRICT wg7Ar loo Mora I PERMIT 1 <br /> f <br /> rORATORY NAME AI ?Nq A oI )jcc � I COUNTY ri+.d0 C 1110I PHONE 1 707 . 465 .DqDl <br /> PLING FIRM 1 140 Na 1yl{(qI PHONE x 707 • `16$ -0L10/TANK ID 1 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> '� ' ° - - r Cii . F Ia n. <.Yt_ r-(,/ fl <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> r <br /> 9- <br /> 39II1 <br /> P y <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N � <br /> PLAN REVIEWER'S NAME � �—� DATE <br /> 1111111111111111111111111111 11111111111111111111111 1 111111111111111111111111111111111111InInII11111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL 'WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> - THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTCR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: )kx&"l Y / TITLE 5f• SrartT 6 -010915r <br /> DATE 6.14 <br /> COND <br /> Lv <br /> H D <br /> `ex- -fes sy <br /> EN. 23 6 (�Re�vised 9/, 11(96) <br /> , T I_ . MF_ /) \ 4Pe9e 3 (�C �''u�`'�•/ _ <br /> i't��^=' ✓f_Av gAU(A„h,.l" ['W�/"w F'(tom ) .c,� V �� ® � 723 <br /> ba c, ® /t4A jqRD 0(� I �.eL - ► o 10� <br />