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PAYMENT -- .r !�o Ed �c V - <br /> -RECEIVED <br /> APR 0 9 1496 dT <br /> SAN J0, JUIN COUNTY S <br /> PUBLIC HEALTH SERVICES SIGN <br /> ENVIRONMENTAL HEALTH DIVISION <br /> - r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APTHISAPERN FOR MIT EKPIRESN90TDAYSPFROMYTHEOSURE OR APPROVALADATE NMDOTIN PLACE 90T WRITE OIN ANYUNDERGROUND <br /> SHADED AREAS. NDICATESUBSTANCE <br /> PERMITSTORAGE <br /> BELOW: <br /> REMOVAL __ TEMPORARY CLOSURE __ CLOSURE IN PLACE <br /> PROJECT CONTACT 8 TELEPHONE # -c ;J )C ICk ''edPl' <br /> EPA SITE # CAC OOI d54 30g <br /> F FACILITY NAMEMy j � ,Z PHONE a '- t <br /> I <br /> j CA <br /> apo fh A'Ir k W a S+oc k+crl <br /> C ADDRESS <br /> L CROSS STREET .+-� KQ . PHONE # 91(0 3�3 g813 <br /> 1 <br /> TOWNER/OPERATOR Ds+im <br /> Y �-� <br /> ��,,.( PHONE # 9110 � IIS <br /> C CONTRACTOR NAME < �, U I-. .SC�'1.C73� �" " �"�� CLASS A I,...� <br /> N CONTRACTOR ADDRESS -I-���j Y��(Qrx Cr <br /> a� CA LIC # �y 5 <br /> a'e).��" WORK.COMP.#,;n2-uN- 33b- <br /> T ry w <br /> R INSURER CA . PERMIT # <br /> Ran I <br /> C FIRE DISTRICT t.;,(1 - , <br /> T PHONE a we-1-13 3 <br /> 0 LABORATORY NAME PHONE # Cl I(p 099 110`1 <br /> RGrtl L..Scl,r-oder �'.OnS 2EII-2-1 <br /> SAMPLING FIRM G,L <br /> 1111IIIIIIIIIIIIIIIIIIIIIIIIII TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- <br /> K 39. <br /> 39- 1 I <br /> 39- 1 <br /> 11111 DISAPPROVED <br /> P APPROVED APPROVED WITH CONDITION(5) <br /> L (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> A11111 <br /> N PLAN REVIEWERS NAME ffiffinuiffilffm <br /> 11111111111111111111 <br /> t CERTIFY THAT IN <br /> APPLICANT MUST PERFORM ALL WOROF <br /> K IN ACCORDANCE WITH SAN JOAOU IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS <br /> SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING: <br /> THE PERFORMANCE OF THE WORK FOR WHICH TN15 PERMIT IS ISSUED, 1 <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWORKER'S IN <br /> SU 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 /> TITLE CJJT4FQ. _ DATE % 9b <br /> ' APPLICANT'S SIGNATURE: <br /> Page 3 <br /> EH 23 046 (Revised 4/26/94) <br />