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SAP -)AQUIN COUNTY PUBLIC HEAL- SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE; <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA IT N CALQ00216468 I PROJECT CONTACT C H T F E 5 TAN S E I E E&I PHONE# q <br /> FACILITYNAME LIBERTY FIRE DISTRICT PHONEN 239 132q <br /> ADDRESS 24124 N . BRUELLA ROAD ACAMPO CA 95220 <br /> RO SSTR ET PELTIER <br /> OWN ROPERATOR LIBERTY FIRE DISTRICT PHONE# 209) 339 1329 <br /> CONTRACTOR INFORMATION <br /> CONTNAME JAMES J I BLIT PHONE k <br /> CONTRACTOR ADDRESS BOX 30331 STOCKTON CA 95 213 CALIGN 365234 1 CLASS "AI' HL <br /> INSURER N/A WORKERCOMP# EXEMPT <br /> FIRE DISTRICT L I B E R T Y PERMIT N <br /> kIABORATORYNAME MCCAMPBELL ANALYTICAL COUNTY PHONE#C925)798 1.64(1 <br /> SAMPLING FIRM RN PHONE k 5 0 z1f q&ca <br /> TANK INFORMATION <br /> TANK IO M 519 <br /> K SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- 615 IINI FADFn GAS I InI .. <br /> L.t 39- 0i5 D PROX DIESEL APR 11. 19 5 8 <br /> 39- <br /> 39 <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9-39APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE.CARTIRES <br /> THE FOLLOWING. 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWSPF CALIFORNIA.' 7 <br /> r <br /> DATE/ <br /> CA . Sd / <br /> APPLIN ,SGFIRE I --O Z <br /> - <br /> CHIEF TAN SE ERT <br /> FLANREVIEwERIS <br /> OVED APPROVED WITH CONDITIONS) 0 DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> NAME <br /> DATEr2 S OZ <br /> ATIONS FROM THIS APPLICATION MUST Be SUBMITTED TO EMD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br />