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05/30/2003 16:36 2094683433 FIFTH FLOOR PA SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK($) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: 1 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE ❑APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPKUVtL) (SEE CONprrION$ BELOW ANDIOR ON ATTACHMENT) DATEb3 PLAN REVIEWER'S NAME ANY DEVIATIONS FROM THIS APPLICATION MUSTD TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK- CONDITIONS: ORK. GOND T FACILITY INFORMATION EPA SITE # & PROJECT CONTACT h,'l B((d PHONE# - Z(v FACILITY NAME 7-61gl0e 112 5fOAM ZZ37— 3219 PHONE# ZQq q 3 ci 4p 1 ADDRESS CROSS STREET 1912CI� A OWNEROPERATOR 7-E PHONE# ❑APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPKUVtL) (SEE CONprrION$ BELOW ANDIOR ON ATTACHMENT) DATEb3 PLAN REVIEWER'S NAME ANY DEVIATIONS FROM THIS APPLICATION MUSTD TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK- CONDITIONS: ORK. GOND T CONTRACTOR INFORMATION . - 11 PHONE#4126%--Z82Co GONTRAOTOR NAME t4,1.4e i e12 r , Ole, I CA LIC # ZqU39 I CLASS CONTRACTOR ADDRESSLIq/to ADDRESS/to i2ligettKO 'x WORKERCOMP# /L/ INSURER ,Wlf 6 r C FIRE DISTRICT roll SfOC kf- PERMIT# GOUNTY Ye PHONE# O-- qi LI BG'O LABORATORYNAME %�r -A FeA -510 PHONE # (Cn O SAMPLINNamsc,z' ❑APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPKUVtL) (SEE CONprrION$ BELOW ANDIOR ON ATTACHMENT) DATEb3 PLAN REVIEWER'S NAME ANY DEVIATIONS FROM THIS APPLICATION MUSTD TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK- CONDITIONS: ORK. GOND T