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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> 'HIS REMNA7, FOR PEAMANEN'+TEMPORAR�CLOSURE OR AEANDONMBNT IN PLACE OF UNCEROROUND YA24FCOU5 SUBSTANCES <br /> STORAGE 1'ANK(SI EXPIRES 90 LAYS FROM THE APPROVAL CATS. CC NOT'ML^.E IN ANY SHACED AREAS. INDICATfi PERMIT TYPE <br /> Z REMOVAL C2 TEMPORARY CLOSURE a CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> A SIT )31 PROJECTooNTACTLorr Ph ONEP <br /> FAC L17 NAIMEI PHONE# <br /> I ACCRESa' 5 N. Hw 88 4e e -R'r , CA <br /> _ <br /> CROSS STFF_ Atkins Rd. - <br /> O`NNER .PEPATOR Lorraine Solari PHONE* <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Jim Thor e I PHCNex <br /> CONTRA COR ADCRESS P.O. B O ° CA LICO CLASS <br /> INSURER Genstar/Golden Eaole '40RKERCC <br /> F;REO;S-R!^T Linden Clements PERWITx=n FP-00004.1il <br /> LAEq RATDRY NAME eoAn; tical ;,ouvx Stan ' DSCN=n 20 - <br /> :;,IF'JNG F''.RIM GeoAnalytical _ <br /> TANK INFORMATION <br /> 'AIJN,:D F TANK SIZE TANK CCN7c`ITS(PRESENTS PASS i DATE INSTALLED <br /> Diesel unknown by Cont actor <br /> ' 39- <br /> ?g. <br /> 39- I <br /> 1'39- I ' <br /> I <br /> 1' 39 <br /> R <br /> APSLICANT MUST PIRF3,RM ALL NARK:N ACCORDANCE -ATR SAN JOAQUIN -CUNTY CRCINANCES.STA-E J:a lS FICLRAL LtWS.ANC !LEES AND ` <br /> 8E3U1A1C43 OF EAN JOAQUIN COV4^ PUBLIC HniLTH SE+VICES. 01-NES CR UCE4SED AGENTS SIGNATURE CERMFI!S 'HE L <br /> ?CQWINC: I <br /> CEPr,Fy ,THAT IN THE?EFFORtMNCE DF'HE A*RK FWANICH THI$PIRMIT S'SSU40 I SWILL NOT!MPL.C',ANY P!RSCH N SUCH A MANNER AS <br /> 70 5EOC'dI SUBJECT TO VCRKIEA'S CCMoENSATION LAWS OF SALIFFRNt,of CONTRACTOR'S HIRING OR SUBCONTRACTING SIONATUF,S CLW IFIES <br /> r+E FCLLONnNQ: •I CER; THAT IN ORM.K'-=OF Kr7R✓JhIC1'TNtS P!n`d;T I$'�SSUED ISHA,.L EMPLC"PE?SON35L'BiECT TJ <br /> COMP:NSATICN UAWS CAp- nA <br /> A=FL,CANTS <br /> Contractor DAr_ 10/30/0 <br /> 5�GNATUR T1TL_ <br /> APFRGVEDAPPROVED WITH CONGiT10NlSi G DISAFFRCV'=L' <br /> (SEE COHCI7ICN5 BE-CW ANC/O'.ON A.TTACHN?BTl / 9 <br /> 1 <br /> ?LAN RE'vI EWER'S NAME DATc <br /> ANY CEYIAiIIONS FROM THISAP°UCATICN MUST se SdSMITiE7.0 84D FORAPPRCVAL PRIOR 70 CO67MsNCING WORN,. <br /> CONDITIONS: <br /> ?x a 3 <br /> IPG'/ISED Ctll OJa<, 5 <br />