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JUIN 2 3 19a J <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE <br /> STORAGE TANK <br /> AP OSNTYABANDONMENT IN RIOUNDERGROUND <br /> SUBSTANCE <br /> THIS PERMITE%PIR 90 DAYS FRCH THEAPPROVALTE. DONOT WRITE IN AMYSHADEDAREAS. INDICATTEPERMIT BELOW-. <br /> REMOVAL __ TEMPORARY CLOSURE _- CLOSURE IM PUCE <br /> OQ� pp/ PROJECT CONTACT & TELEPHONE # C� '3 . �- <br /> EPA SITE # - 00 LJ �v..� PHONE # <br /> F FACILITY NAME �IQ'�-� ollc'z /7 <br /> A <br /> C ADDRESS r•c"� <br /> I <br /> L CROSS STREET ��� PHONE # <br /> I Z� 7— <br /> T OWNER/OPERATOR <br /> Y �-O PHONE # (916) 928-8300 <br /> / <br /> C CONTRACTOR NAME Advanced Environmental ServiInc.ces, cuss <br /> D 1419 North Mark vd. Suite 5 CA LIC # - <br /> ,H CONTRACTOR ADDRESS - I Y0RK.CCMP.#NWC-274486-00 <br /> T <br /> R INSURER Golden Eagle Insurance Company PERMIT # �b'�.,iTe <br /> C FIRE DISTRICT t5/vclG/-0 N <br /> 0 LABORATORY NAME 0A1 / /u (GE I PHONE # Cj !� Z-? 5 -lb Sc7 <br /> R iST D G�•cgN2 <br /> SAMPLING FIRM <br /> IIIIIIIIIIIIIII IIIIIIIIIIII II TANK SIZE 5� Un1 <br /> �� CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE LIST INSTTLL <br /> ED <br /> ' <br /> TANK IDS / K <br /> 39-� ZZ- <br /> fa UU <br /> T 39" - O�/ <br /> O/'� EG (JAIL NX <br /> A 39- <br /> N 39- 0 <br /> K 39- <br /> 39- <br /> 39- <br /> illlllllilllllllll VIII III IIII III II �I(l III It I I I I 1111111 Io I�PPROVEDIIIIIII IIIIIIIIIIIIIIIIII <br /> P P APPROHM YI COWTIONCS <br /> L / (SEE ATTACHMENT.Y COIDIT S) DATE ! __ <br /> A E IIII <br /> N OLAH RFVIEYERS NAME <br />�{[1 TIfl11I11111I1I1IlII STATE LAYS, ANO RULES AND REGULATIONS OF <br /> AGENT'S SIGNATURE CRTIF i'c5 THE !CLLWIHG: "I CRTSFY THAT IN <br /> APPLICANT .`UST PERFORM ALL YdtK IN ACCORDANCE O WITH SAM CENSED COUNTY SIGNATURE <br /> OR LICENSED ANY PERSON <br /> IN SUCH A MANNER AS TO SECCME <br /> SAN ,OAOUIN COUNTY PUBLIC HEALTSERVICE PERMIT IS tS�EO I SHALL NOT EMPLOY TRACT IMG SIGNATURE CERTIFIES THE FOLLOWING' <br /> THE PCRF0RMAH= OF THE 'WORK FORHIRING OR SUBCONTRACTING TO YORKER'S <br /> SUBJECT TO WRKER'S CCMPEHSATICN LAYS OF CALIFORNIA-' CONTRACOR'SI SHALL EMPLOY PERSONS SUBJECT <br /> "I CRTIFT THAT IN THE PERFGRMANC OF THE YORK FOR YN[CN THIS PERMIT [S ISSUm, ` <br /> CXIPEMSATICH LAYS OF CALIFORNIA.° <br /> f GATE <br /> TITLE_�.VV '✓�H�7L <br /> APPLICANT'S SIGNATURFC� <br /> Page 3 <br /> F'H 23 0G6 (Revised 4/26/91 <br />