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ENVIRANMENtALMALI LnV101Am <br /> ,330044 Weber Ave.Third Floor <br /> Stockton,CA 95201-0388 <br /> Phone: (209)468-3420 <br /> Approved <br /> Approved wNh chargee: See Remarks <br /> ❑Disapproved: See Remarks <br /> Remarks <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOaVE PERMIT �--f5-C By <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND N ZA S SUBST NCE STORA K <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY EhOVM/BI '�Sewam& my to that <br /> REMOVAL TEMPORARY CLOSURE whl Ia N w and desC."bed hereon but <br /> loft <br /> EPA SITE #N-r O PROJECT CONTACT 8 TELEPHONE Or <br /> F FACILITY NAME L <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y Af- -P.�-— -,5-10- P Z3.3 c) <br /> C CONTRACTOR NAME Af, ad Oct kk t PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS 2 LO �t. �� CA LIC # 59zc�1,0 CLASS pL�i.I7 <br /> T I <br /> R INSURER WORK.COMP.# �WG C> - 3 <br /> A <br /> C FIRE DISTRICT VVl4'r' 1�..U0 M PERMIT # FQ_�i(QCXX)20 <br /> T <br /> 0 LABORATORY NAME PHONE # SI 0. 'Z• �.� <br /> R <br /> SAMPLING FIRM 0,-L � _ �`0 PHONE # 10 , -z . 't`O <br /> I I I I I I I I I I <br /> TANK I I I I I I I I Il 1 1 fl <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- - <br /> ID,r ,o k LLJ.U�i4pEln �iASdL �uE 1 <br /> T 39- /I-'-IJOFJ K- Y')i <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIII IIIIIIIIIII II IIIII11111111111 �IA4iIIIII 1111111 IIIIII111111111111111111111111111111 II IIIII I 111111111111 <br /> L APPROVED �/ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (S A ME T WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 9L. DATE �P <br /> 11111111111111111111 11111 <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: "1 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." b� r <br /> APPLICANT'S SIGNATURE/L�K!C-EI�rGLJR'I�3 TITLE /AyC'&4L-&,AUfffj #A-TELT <br /> ✓1 ,'hon5 C1Sc%U r4'�. -�.� -11(Oil 4a"f`Ql `'icb-lpL fog <br /> —CPQ- <br /> �1 <br /> `T�>7-xcud F-) U <br /> EH 23 046 (Revised 4/26/94) Page 3 <br /> C�� 1 ttr„r.y� <br /> c.JL� I,L.V�47.S <br /> �r�� l � C2 u�(InLIKL�Iw" /,S— <br />