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=E: E E 1 tt S1 c <br /> 7-17-OS; 8:26AM; <br /> 07/1612003 15:50 2054603 FIFTH F'LCSR PAGE 02 <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ! ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTrtEh1P013ARYCLOSUAE(1REIBANDON+NIENT4N PLtiCE OF LJNDEPtGR4UIvD}iAZAR4CIUS 5UB5TANCES <br /> STORAGE TANK{S}EXPIRES 90 DAYS FROM-fHE APPROVAL DATE. CO NOT WRITE IN ANY SHADED AREAS. 1NCICATE PERMIT TYPE; <br /> " REMOVAL ❑ TEMPORARY CLOSURE [I CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE«G,7 PROJECT CQN7Ac r r T FHQiNE "117`t-`ILOS—IZa�.sO <br /> FACILITY <br /> �rtaN�# <br /> ADDRIZ5S owl <br /> CRCSSSTREET <br /> CIWNEROPERATaR Li8G7r� PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR I+fA',1E C--P � — <br /> CON7RA'131k ADOPES5 ) CA L1C ' 1 CLASS <br /> INSURER i (J Y f� WORKSR COMP-, �4 <br /> FIRE DISTRICT FIERMITO <br /> WBORR7aHY NAME COUNTI' PHONE r, <br /> SXMPLING FIRIM r <br /> TANK INFORMATION <br /> 4 M75E <br /> CONTENTS PRESENT$ PAST DATE INSTALLED <br /> t <br /> aL <br /> APPLICANTMUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 19ACUiN COUNTY C)RolNANCE5,STATE LAWS,FEDERAL LAWS,AND RULE'S AND <br /> R6G' LATION5 OF SAN JOAOUIN COUNTY OLIeLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURc CERTIFIES'NS FOLLOWING: 9 <br /> CERTIFY THAT IN THF PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS tSSUEO,I&WALL NOT EMPLOY ANY PER60N IN V CH A MANNER AS <br /> TO RECCWIE SUIdjECT Tp WORKER'S COMPENSATION LAWS OF CALIPCRNLA' COW P.AjCTOA:S HIRING OR SJOCONTRACTING SIGNATURE CIs17TI5IES <br /> Tris FMWWING'. 1 CERTWY THAT IN TH6 PERPORMANG OF. S WORK F.7R WHICH THa PCRMrr IS ISSUEO,I SFIALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CA NIA' <br /> APPLICkNT'S SIGNATUR5 lGf TITLE <br /> ❑ APPROVED ROVED WITH CONDITION(S) [J DISAPPROVED <br /> (SEE D.TfONS BELOW a�fD10R QIP A1-IAGNMcNT) <br /> PLAN REVIEWER'S NAME <br /> WE <br /> ANY DEVIl171QNS r-RQM THIISI APPLICATION MUST B USMIT7ED TO E81)FOR APPROVAL PRI TO COMME_NCIN WORK. <br /> CONDITIONS <br /> i <br /> I <br /> EH 23 046{REVISED 66113199) Page 9 ' <br />