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I2/11/ZUU4 14: Ua nnw <br /> FEB-ac'04 17:48 FROM-KLEEMAN ROEBRELF 916-939-1166 - T-746 PA7/11 F-539 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> iAPPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURfi OR APANOONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES BO DAYS FROM THE APPROVAL DATE. OO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> )(REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE F PROJE CONTA GF= PHONED qlAS='101-469 <br /> - <br /> FACILITYNAME J" G 1�'TGi F'/C RE/L- PHO <br /> ADDRESS �v vy -v- .4syGeY `PtiE SzJ�— <br /> CROSSSTRGET � PP AJ A/� <br /> I Ow ER OPERATOR -S'B C PHONED -' <br /> I. <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME P ON6D - D <br /> j CDNT AC RAPPRES6 G LO C ^ O CLASS <br /> O <br /> WSURER E w1.Sdrt.�4.-.r�2� . E O Qm0 / <br /> FIRE DISTRICT E IT a <br /> I LASORATORYNAME G .A COUNTY - PHO E <br /> SAMPUNGFIRM LI PHONE F <br /> TANK INFORMATION <br /> TANK 1)D TANK SIZE TANK CONTENTS IPPESENT& PAST) QA19 INSTALLED <br /> 39- OZ ,000 �Ac J/esez FuE< Flw s7wry .Sry /9B8 <br /> 39- <br /> 39- <br /> 39- <br /> 139- <br /> APPLICANT <br /> g39- <br /> 39- <br /> 39-APPLICANT MUST PERFORM ALL WORK IN ACCOROANCE WITH SAN JOAQUIN COUNTY DROWANCOS.STATE LAWS,1`20ERAL LAWS.ANO RULES AND <br /> PEOU. TIONS OF SAN 40AGUIN COUNTY PUBLIC HEALTH S6FMCES. OWNER OR UCENSEO AORHT S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTEY TMT DI T.4F PERFORMANCE RFOCE OF THE WORK FOR WHICH TH15 PEPM(T 15 ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO aECOUE SUBJECT TO WORKER'S MMPSNSATION LAWS CP CALIFORNIA.' CDA7`RACTOR'6 HIRING OR 4UPCONTRAGTWO SIGNATURE CERTIFIES <br /> THEFOLLDWr+G -1 CERTIFY THAT IN THE PERFORKAWE OP THE WORK FOR W61UM THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKBR'SCOnPEN9ATION NW\SO�;Fj�jVLJIF�O�R�mL/A' Q L2 � <br /> _ APPLICANT'S SIGNATURE ✓-• "• TITLE S��/ �- !✓lj t cL M�ti DATE 2 <br /> ❑ APPROVED PIAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> - IEEE CO PRIONS BELOW MOTOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY OGVIATIONS FROM TH19 APPLICATION MUTT REV,IMMITTPID TO 9HO FOR APPROY PRIOR TO COMMENDING WORK. <br /> - <br /> CONDITION: <br /> EH 23 348(REVISED 00115199) Paea 9 ' <br /> RECEIVED FEB-11-04 15:09 FROM-9168591011 TO-KLEEMAN RDEBBELEN PAGE 05 <br /> 10/15/04 FRI 07:44 [TX/RX NO 85471 004 <br />