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4-0B_1998 8:55AM FROM TAIT SACRAMENTO 916 635 2606 <br /> P- 5 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EO-MONMEN'TAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMT <br /> THE PERMIT FOR PERMANENT/TEMPOMY CLOSURE OR ARANDONNFNT IN PLACE OF ONDERGROIAIO RA7.ARIIMS SURSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL`DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 7. REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> PROJECT CONYACY & TELEPHONE BTi4♦T /ISdIa1Tt3 S/ <br /> EPA SITE k CP11,5b) QARN6� <br /> PRUNE N <br /> F FACILITY <br /> z ZKj� �g-t�342 <br /> AnJ q f Z07 <br /> C ADDRESS <br /> I _ <br /> L CROSS STREET orc:i 'qqp <br /> I PRONE C <br /> T OWNER/OPERATOR r- .a A,pk �,�, ra,rrPti'v�J (7/4 4ZS'- <br /> Y �p 64 <br /> 1 PHONE #( S/O—/'� <br /> C CONTRACTOR NAME �C]n✓1S E' C-plVf4 /NG <br /> G w LIC r /$ c3 CLASS A //AZ <br /> N CONTRACTOR ADDRESS <br /> T WORK.CHP.N S�Zi '�rly <br /> R INSURER _75 (IND <br /> PERMIT @ <br /> C FIRE DISTRICT /Ty <br /> NAME rJ� (J(3/A1 'Nl/1� 6✓1QG pNHE #T 36-4- <br /> -ALL <br /> 0 LAMMA9RY <br /> R <br /> SAMPLING FIRM `//�rrCt7L yA'n)3 . . PRONE # (q l$ 8T`j <br /> 11111 1111111111 111111111111 L TANK SIZE <br /> r J CHEMICALS )TORE4 WR RENTLYIPREVIOUSLY DATE ZTo �7 LIED <br /> 77 AI 110 N �0. <br /> 39- v q Jro� <br /> T 39- .nas vi - <br /> A 39- ------,---- <br /> N 39- <br /> K 39- <br /> 39- <br /> S9- ! 1 <br /> P Illi <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR 00 ATTApRIENT) <br /> DATE <br /> PLAN REVIEWER'S NAME ///111 i C"✓ <br /> IllllullllutllttllllltllllIIIl1111F1111111111i111il11p11111111111lltttlllllllllll1111UI1lIElllll 1111l1111111[Hillillltli <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOVING: 1'1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECCMF, <br /> UI JECTI FO IVDRKFRTHAT NS7COHE MPENSATION <br /> NCE OF OFCALIFORNIA. <br /> ALLRKRNIAOR WNICH�TRACTHIS PERNITHISL ISSIIEDmr, OR �6 SNALLCENPLOYTING I PER Sll&IECTGNATURE EYOTHNORKR+OWING:: <br /> COMPENSATION LAWS OF CALIFORNIA-" <br /> TITLE 0✓C'(Cr—,_!I`'+ / DATE S' /fo <br /> APPLICANT'S SIGNATURE: r 1rTy7 <br /> CONDTI'IONc51. / r a n �f <br /> IN 23 046 (Revised 9/ 96) Page 3 <br />