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1 /1bf1bI4'1 by:3� 1b�46N�433 FIFTH FLOOR PAGE 141 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> 1 THIS PERMIT FOR PERMANeNT(TCNIPO_ARYCLO8tJRC=OR ABANDONMENT IN PLACE OF UNDERGROUND HAZAROOUS SUIlSTANCES <br /> STORAGE TANK(S)EXP[RE5 90 DAPS FROM THE APPROVAL DATE- DO NOT WRITE IN ANY SHACIED ARLAS- INDICATE PERMIT TYPE: <br /> 0 REMOVAL TEMPORARY CLOSURE CI CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE P PROJECT CONTACT PHONE# <br /> FACILITY NAMrtGT C- -- PI4QNE - <br /> OHESS lio,51 p)cwtvn j1vf*Q. C!9 S�nS <br /> CROSS STREET <br /> OWNER OPERATOR QIiT 3 PHONE tF �3 <br /> CONTRACTOR INFORMATION <br /> CONT TOR NAMEPHONE It jt}l 66 <br /> GONLTRACTOR ADDRESS 11101 1 CA LIC# el'34 700 CLASS <br /> INSURER T e.L"nm WORKER COMP» 7 <br /> FIRE DISTRICTPERMIT S-+�I+�b �Fe7n <br /> LALORATORY NAh1E APlq COUNTY A; PHONE X <br /> Wtq <br /> SAMPLING FIRM PHONE it <br /> TANK INFORMATION <br /> TANK 10 A TANK SIZE TANK CONTENTS(PRESE=NT& PAST DATE INSTALLED <br /> 397 I 4Sd l,x. <br /> 39- <br /> 39- <br /> LL 39- <br /> 39- <br /> APPLICANT WUST PERFORM ALL WORK IN ACCORDANCE WIYH SAN JOAQUIN COUKTY OROINANCI~S.STATE LAWS.FEDERAL LAWS.AND RULlES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PU9L1C HEALTH SERVICES, OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING; -1 <br /> CERTIFY THAT IM THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT Eu>PLDY ANY PERSON IN SUCH A MANNER A5 <br /> T'D HECONIE SL18JECT TO WORKER'S COWENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CFFRTIF[E5 <br /> THE FOLLOWING- -1 CERTIFY THAT LN THE PERFORNMNIZE OF THE WORK FOR Wf11CH THIS PERMIT 15 15Sl1EC.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA' a <br /> ' APPLICANT'S SIGNATURE 1 TITLEf'DR r l IODATE �fr� ` <br /> ❑ APPROVED FIAPPROVED WITH CONDITION(S) © DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN RFVIEWER'__f, ` BATE <br /> ANY OEvWTIONS FROM THIS APPLICATION MUST HE SUBMITTED TO END FOR APPROVAL VRIQR TO CdMMENCING WORK, <br /> CONDITIONS: <br /> EH 23W6(RENASCD OaIIW!94) Page 3 <br /> i <br /> 12/10/02 TUG 09: 43 [TX/RX NO 87091 [6007 <br />