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1111b/1bbL b�: 3� Lby4bkiJ4� I-l}- IH FLUUK HAUL 02 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMAINENTfrEMPORARyCLOSURE OR ABANDONMENT IN PNCE.0P UNIDERGROUND HAZARDOUS SU13$TANCES <br /> STORAGE TANK(S)EXPIRES 9Q OAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INOICATE PERMIT TYPE- <br /> 0 REMOVAL C- TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITS: 7 PRGJPCT CONTACT PHONES Q257SY3 <br /> FACILITYNAME QRkG3Gtc, 92, L PHONE e42 S2'3 a36t, <br /> ADDRESS 1500 ZC-.'-gt i=a I ,%<, <br /> CROSS STREET <br /> OWNER OPERATOR ?AeAlPIr-$C41 &v, 5V45• Rrn 3EVW,5 fI lgtl3 L PHONE# 14Ts2s &96b <br /> CONTRACTOR INFORMATION <br /> CQNTRACTOR Nf1 <br /> AMs Jbr a� L ,1rC PHONE lI 701 '741 <br /> E66g <br /> CONTRACTOR ADDRSS 'I l a,1DU lrr%0l We SI,O CA LIC# CLASS AJN <br /> INSURER PIC (►fnM54TIOf' I V &fCf 6V- WQRKER COMPir V-QD3298 � <br /> FIRERISTRIGT tfL- a PERMIT# °4�cnpi+�b <br /> tA80RATORYNAME COUNTY PHONE* 1 <br /> SAMPLING FIRM Mle PHON8 N 14 <br /> TANK INFORMATION <br /> TANK IQ 1; TANK SIZE TANK CONTENTS PRESENT B PAST GATE INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9-39- <br /> 39APPLICANT(JUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQU(N COUNTY OROINANCES,STATE LAWS,FEDERAL LAWS,AND RULES XN0 <br /> REGULATIONS OF SAN J0443UIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S "NATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERfORIJANGE OF THE WORK FOR w"C;H THIS PEReAr IS WLIE0.1 SxaLL NOT EMPLOY ANT PERSON IN SUCH A MMNLR AS <br /> TO BECOME SUaJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OA SUBCONTRACTING SIGNATURE CF1311FIES <br /> THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANQE OF THE WORK FOR WHICH THIS PSRMlT IS ISSUED,I sNAIL EMPLOY PERSONS SUBJECT TQ <br /> WORKER'S COMPENSAYION LAWS OF�CALI�FORN]IIA,'Lln� h <br /> APPLICANT'S SIGNATURE_ ice" }' _"f f?�� TITLE A 6 jkA i'D12 P �I IC&'lj�)ATV. I1-ZG-d 2 <br /> ❑APPROVED APPROVED WITH CONDITION(S) 13 DISAPPROVED <br /> (SEE CONWTIQNSLOWANOIOR OfV ATTACHMENT)PIAN PEVIEWER'S DATE \- b <br /> ANY DEVIATIONS FROM 1141S APPL(CATION MUST HE SUBMITTED TO EF(O FOR APYRISVAL IgPT4 COMMENCING WORK. <br /> CdNDITIONS: <br /> EK 23 W(REVISED 0811319(3) Page 3 <br /> 12/10/02 TUE 09:43 [TX/RX NO 87091 Q002 <br />