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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />HAZARDOS <br />ANCE <br />APTHISAPERMIT EXPIRESN9OTDAYSPFR0IM THE APPROVAL ADATE. DOTN T WRITE IN PLACE OIN ANY ESHADED OAREAS. IINDICATET STORAGE <br />PERMITTYPE BELOW: <br />V nDADV rinuior CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />2 <br />CA17gUl 515 iqJ PROJECT CONTACT <br />8 TELEPHONE #JIM {P(,!fo�12, 2zq 8-4Z-+7,T� <br />PHONE # <br />AME NfIol & <br />=llb� <br />7��y /�.-�'TI T �_ � l {b TEET <br />�� �hV-4 - <br />RATOR TrQ 11�AT usa� . <br />C <br />CONTRACTOR NAME Bp(tCA P�i�oLCuM <br />PHONE <br />D <br />N <br />CONTRACTOR ADDRESS <br />CA Llc # 3g1n5 5 <br />CLASS k/$ RA -6 <br />TS <br />WORK. COMP.#gg <br />R <br />INSURER A�qeLJ�. <br />!•CK-GI�L..A <br />A <br />PERMIT # <br />C <br />FIRE DISTRICT <br />PHONE # <br />0 <br />LABORATORY NAME - rU <br />R <br />PHONE # <br />SAMPLING FIRM ft5z+tf�JuLf lta l <br />TANK ID # TANK SIZE <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DAT UST INSTALLED <br />39- 3 — Jmv) /a1Y11DIQ <br />t-�1 Anmun! SRA -2843 <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />r <br />P <br />L <br />APPROVED ADPR04ED YIiN CONDITIONS) DISAPPROVED <br />(SEE A YACHMENT WITH CONDITIONS) <br />A <br />!� <br />N <br />PLAN REVIEWERS NAME ti -a✓ <br />11111111111111111111 <br />DATE <br />(jjn11111TTfffffTT 111111111111111111111111111 MR <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE (PITH SAN JOAQUIN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />AS 70 BECOME <br />THE <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S <br />FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK <br />COMPENSATION LAWS OF CALIFORNIA. - <br />APPLICANT'S SIGNATURE: <br />TITLE DATE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />2 <br />