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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 /> ^�. _ x REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE X ef't�- � ",I�b PROJECT CONTACT d TELEPHONE X -r( . 4 <br /> A FACILITY NAME eUJ lIeo ,��edn�,.t(y� PHONE @ 2a•' S1ZJ�77Zc')O <br /> C ADDRESS i1�(V00 /L1 .�u1 <br /> L CROSS STREET l_!.L(1.(Yv d <br /> I <br /> T OWNER/OPERIAATTOR a 1 PRONE # G <br /> Y AA-ATC-CA. 1.1.411 <br /> OC CONTRACTOR MANE �ra„ PHONE 'W (209) 524-9653 <br /> TCONTRACTOR ADDRESS 1217 S. 7th St. Modesto, 5 CA LIC x 449864 cuss A,-8,C61/D40R INSURER Ca1coD)p Insurance Canpany <br /> A WORK.CAMP.X W964137662i <br /> C FIRE 0(STRICT K _�p (�. PERMIT X <br /> T <br /> 0 LABORATORY NAME GeoanalytiCal Lab N StanD.slaus PHONE 'W (209) 572-0900 <br /> R <br /> SAMPLING FIRM Geoanalyti <br /> Ililllllliilllllllllllllllllll PHONE x (209) 572-0900 <br /> TANK ID T NK CAEMICALS STORED CURRENTLY/PREVIOUSLY 0 IE UST INSTALLED <br /> 39- d a(eseip &ellT 39- <br /> 2. <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111111 I I I I IIIII I I lllllllilllilll 1111111 IIiTrTll�liIIIIIIIII! <br /> L APPROVED `/ APPROVED WITH CCNDITION(S) _ DISAPPROVED <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAM DATE H <br /> IIIlillllllllllllllllllllllllllllllll IIIIIIIIIIIIIIillllillillillllllllltllllllllllilllllllllllllllllllllllllllllllllllllll <br /> APPLICANT MUST PERFORM ALL WORK IN 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 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." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PER FOR CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN <br /> APPLICANT'S SIGNATURE: L- TITLE DATE L-q 7 <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> A"164- -(�o��OLZ C_Fxl -P.F-\ <br /> C�4S0\i cV E �T71N IL• <br /> 2� �iQiw>C� SRr�1Pls� Cjza �cz��u V��-f' � (lmw Sa,'•-�Pl;�� G.S <br /> t- <br /> EX 23 0" (Revised 7/10/96) `Page 3 <br />