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lviv v <br />7ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR,IDERGROUND STORAGE TANK.OSURE PERMIT <br />rSTOR <br />PERMIT FOR PERMANENT!'fE41PORARYCLOSURE OR AS <br />ANOONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />AGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHACED AREAS. INDICATE PERMIT TYPE: <br />9 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />TANK INFORMATION <br />TANK ID X ' TANK SIZE I TANK CONTENTS (PRESENT I PAST) DATE INSTALLED <br />FACILITY INFORMATION <br />1000LLY�1 <br />c 7 <br />EPA SITE #I <br />-LOO'a PROJECT CONTACT AMbJE AG <br />PHONE# 2fA- <br />PHONE 7I Z&) (-q <br />FACILITY NAME <br />�f Q -T <br />INSURER State Fund Insurance <br />AOORESS <br />FIRE DISTRICT <br />I PERMIT# <br />CROSS STREET <br />-,�n.�'a <br />EaA-7 <br />PHONE # 204 - 434-�531- <br />OWNER OPERATOR <br />AIIIII/J8TT67 HOAG <br />_ <br />TANK INFORMATION <br />TANK ID X ' TANK SIZE I TANK CONTENTS (PRESENT I PAST) DATE INSTALLED <br />CONTRACTOR INFORMATION <br />1000LLY�1 <br />c 7 <br />PHONE* 209-524-9653 <br />CONTRACTOR NAME SF21C0 <br />1 21 7 South <br />7th Street CA LIC # 449864 CLASS 1 <br />CONTRACTOR ADDRESS <br />I WORKERCOMP# 007108-98 <br />INSURER State Fund Insurance <br />ComPanY <br />FIRE DISTRICT <br />I PERMIT# <br />LABORATORY NAME GeoAnal 'Cal <br />COUNTY PHONE* - <br />SAMPLING FIRM C�c'OARalVticdl <br />PHONE x 209 572-0900 <br />TANK INFORMATION <br />TANK ID X ' TANK SIZE I TANK CONTENTS (PRESENT I PAST) DATE INSTALLED <br />39_ �I Cyf;C:= <br />39- )-b <br />1000LLY�1 <br />c 7 <br />U�Jk xx.v1 Fikr�uGr U0Y�a�L l <br />jA4jeJl0AJ 7�Cci,n AsD t-� Lt dk 0 <br />39- <br />39- <br />GATE -I <br />PLAN REVIEWER'S NAME <br />1 39- <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />39 - <br />CONDITIONS: <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS. FEDERAL LAWS. AND RULES AND <br />REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR UCENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br />i0 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING'. 'I CERTIFY T�(AT IN THE P�RFORMAI Q�THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECTTO <br />WORKER'S COMPENSATION WS F I R /r� <br />APPLICANTS SIGNA <br />TITLE / 64C �I -6OX Z' DATE Y l2 <br />A HAZ <br />ASB C <br />❑ APPROVED <br />v <br />APPROVED WITH CONDITION(S) <br />Cl DISAPPROVED <br />(SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br />GATE -I <br />PLAN REVIEWER'S NAME <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />_ <br />L G <br />q -t 0dva4vu fzel <br />EF1 23 0Afi ,REVISED :Cl19/98) P39e 3 <br />