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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 /> REMOVAL _ TEMPORARY CLOSURE X CLOSURE IN PLACE <br /> EPA,SITE # PROJECT CONTgCT 8 TELEPHONE # <br /> F FACILITY NAME RICHARD 0. BYWATER PHONE # 209-942-3132 <br /> A <br /> AooatsS <br /> I 3132 FARMINGTON ROAD STOCKTON, CA 95205 <br /> L CROSS STREET MARIPOSA ROAD <br /> I <br /> T OWNER/OPERATOR �€€ <br /> Y RICARD 0. BYWATER 209-942-3132 <br /> C CONTRACTOR NAME MR, B' S ENTERPRISES, INC. PHONE # 209-942-3131 <br /> 0 <br /> N CONTRACTOR ADDRESS P.O. BOX 31600 STKN. 95213 CA LIC #A539841 CLASS A <br /> T <br /> R INSURER CALIFORNIA INDEMNITY wRK.ca1P.#EK16625B <br /> A <br /> C FIRE DISTRICT STOCKTON PERMIT # 13988 <br /> T <br /> 0 LABORATORY NAME F.G.L. ENVIRONMENT COUNTYSAN JOAQUIN PHONE # 942-0181 <br /> R <br /> SAMPLING FIRM SAME I PHONE # 942-0181 <br /> 39- <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- - , f tL,Ar / <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A E CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME 14 DATE <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: 9 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 CALIFO IA." <br /> Lo <br /> APPLICANT'S SIGNATURE: D ' - t TITLE J [Tf DATE <br /> CONDITION(S): <br /> �-�-- <br /> CT <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />