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0 0 <br /> SAN JOAQUIN COUNTY COPY <br /> PUBLIC HEALTH EIYVIROMIEIINTAL HEALTH DIVISION VICES <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE E OR <br /> EXPIRESMIT FOR 90 DAYS PFROMNTHE/APPROVAL TEMPORARY <br /> DATE. 00 NOT BWRITEMIN TANY SHADED PLACEOUNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANAREAS. INDICATE PERMIT TYPE BELOW: <br /> K <br /> REMOVAL TEMPORARY CLOSURE <br /> EPA SITE # —_' CLOSURE IN PLACE <br /> A 0-7 Qy PROJECT CONTACT <br /> F FACILITY NAME / B C,i <br /> ADORES <br /> IS l PHONE # ,j <br /> L CROSS STREET CAVA <br /> 1 <br /> T OWNER/OPERATOR <br /> Y USA Q)ASQ(, ,4D0.- C21 <br /> PHONE # <br /> C CONTRACTOR NAME / n — <br /> 0 LCJK1 <br /> N CONTRACTOR ADDRESS �.;c'�7� OWNy.L � PHONE # 0 <br /> R INSURER C�. _ CLASS <br /> C FIRE DISTRICT WORK.COMP,# <br /> I <br /> 0 LABORATORY NAME S COUNTY PERMIT # <br /> R 0 V1. .6� PHONE # <br /> AMPLING FIRM +<NhJ <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIS <br /> TANK ID # <br /> 39- TANK SIZE PHONE # <br /> 7 39- 6`00 CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST <br /> A 39- INSTALLED <br /> 1 _ ri <br /> � ; <br /> N 39- - ---��. <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39-39-P I II1111111II Illilitl I I i l l l 1111 11 <br /> L <br /> A __ APPROVED ��IIIIIIIIIII II I <br /> APPROVED WITH CONDITION(S) <br /> N (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> ISAPPROVED <br /> PIAN REVIEWER'S NAME <br /> DATE <br /> IIIIII11111111111111111111111111111111111111NIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111111tllllllllllllllllllll� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FO <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, REGULATIONS OF <br /> SUBJECT i0 WORKER'S COMPENSATION 1 SHALL NOT EMPLOY ANY PERSON FOLLOWING: "1 CERTIFY THAT IN j <br /> "I CERTIFY THAT IN THE P LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR MANNER AS <br /> i0 BECOME <br /> COMPENSATIONCALIFORNIA."NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMP IES THE FOLLOWING:: <br /> LAWS OF CALIFORNIEMPLOY PERSONS SUBJECT TO <br /> WORKER'S <br /> APPLICANT'S SIGNATURE: <br /> TITLE <br /> i✓ SII <br /> DATE <br /> CONDITION(S): <br /> EH 23 01,5 <br /> q 3 <br />