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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONh-(ENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS?ERN1:T FOR?ERo p�gp gYiSORGM THE APPROVAL DATE. CO NL•'NRt"E IN ANY SHACeD AREASDIGATS P SUBSTANCES ITTY <br /> STORAGE TANIC(3)Ek• <br /> F6 REMOVAL <br /> ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> la <br /> FACILITY INFORMATIC <br /> 2 PROJECTCONTAOT Roger Varwi 'HON <br /> oA gRE k I PHONE <br /> FAC.LI^(NAM° <br /> ADcasss Brandt Rd. Lodi CA 95240 <br /> COsss-FEE- Jack Tone PHONE - <br /> OwN „peRp70R L.R. Varwi <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME Jim Thor e Cauca Cuss <br /> C.O,NTRAC-OR ACORESS P.O. B 57 qr)'yyORKER CGMPC ' <br /> INSURER Genstar/Golden Ea le PEPX,IT# upon a royaDiS-RACY O e umne l <br /> FIREINn� _ <br /> S,AgORATORYNA E eo na Y lca a S mCNE s tan oHCNEn 209 <br /> SA: FLING FIRM eo na 1Ca abs <br /> TANK INFORMATION <br /> AANK!G A TANK SIZE TANK CONTENTS(PRESENT 3 PASS <br /> DATE INSTALLED <br /> 3y 2,000 al. � unleaded asolin ' <br /> 3� I <br /> ay- <br /> 1n39- <br /> 39- <br /> v 39- <br /> RE U T.S Of cE�A19 RMO40A ISN Y^.�CRtI”`PUBLIC HEALTH SEWCES.RDANCE ATH GAN A0%.^ER OR UENA LAWS 1! <br /> CUNTY SEC,C•aGENT9 SIGNATURE <br /> C R FI�THE4NX ANO <br /> I TG TIFY T E T IN THY T�ORAANCE'17- MANNER as <br /> ESA-,jCq L%'A 0?CAUFORNU?W41CH-.HIS 'T CONTR CTOR' HIRING OF 3U3CONTRACT NG 19UGNATUFe e'IFIE9 <br /> LAm%,C,"�T-S <br /> 'ICEnT'pYTHATIN`FEPSiFORMANCEOFT HE'.vOR%FCRNMIC-HTHi9PEnPdRIS:SSUEO4SNA-LBdPLC"PEPSONaSUE+e,.T-C <br /> S COMP-NSATCN UA"VS OF SIGNATURE <br /> TITLE Contractor OAT-_ 11/15 2 <br /> G A?PROVEDQXPPROVED WITH CONDRION(Si ❑ DISAPPROVED <br /> (SEE CCcN'OL/-IICCHS B!,OV'i A1C/CR ON P.TTACNM:NT, <br /> �{ <br /> PLAN RE'vl@NER'S NAMER <br /> f ANY C°`IIA^•ONS FROM T415 A?'LICA.TICN MUST t. <br /> :E 3L'BMITTEO TC EHO FOR APPRC JAL PRIOR TO COMMENCING 4 <br /> GOND T1dNS: I , <br /> cy.7 94E(REVISED 08r7Cl99; <br />