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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE 41 i 11 - - v - • - - a wszv- vf4wj 6' !/ % Z - l 'y / v CONDITION(S): EH 23 046 (Revised 9/11/96) Page 3 1-1 EPA SITE r — a /f ( -� PROJECT CONTACT & TELEPHONE # '64ti/ lf� 7 - 0 3o5 F FACILITY NAME S 6-0 Y -D C �� PHONE # Z09'- u.�17-O3Q� A C I ADDRESS " l o ( �a C ,/ � t / iv/a ` I L CROSS STREET -rqN " t> lei US ✓ I T OWNER/OPERATOR A PHONE # Y b lolo Zoe ,l/-6 -030-C u oxJ / C CONTRACTOR NAME 5TIW Lr G/J VL D �/ PHONE #20 9 3 0.- N CONTRACTOR ADDRESS v% I, q7 J7# �j CLASS 2 7 ,L,) S SC CA LIC # /T e 9,7— T R /- INSURERS'�� T� �u WORK.COMP.# i'n' C� 1"I C� A � C FIRE DISTRICT PERMIT # T 0 LABORATORY NAMEpbt pVlCOUNTY n j �Q o -1- PHONE # 6 10 — � Q g - /6 Zo R SAMPLING FIRM V¢ /li[ �' -e 40 �Ut Qbh� L PHONE #70f r, 1111111111111111 III(IIII II TANK ID # TANK SIZE C EMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- f J3 h Cjy0 I- A 39- - L Z, a e0 N 39- K 39- 39- 39- illilllllllllllllllllllllllllllllllllll IIIIIIIIIIIIIIIII1111 P L IIIIIIII1111111111111111111111 III11111111111111111111111111111 APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED AEECONDITIONS A BELOW AND/OR ON ATTACHMENT) N PLAN REVIEWER'S NAME L` ' DATE - J I I I I I I I I I I I I I1111111111111111111111111111111111111111111111111 I 111111111111111111111111111111111111111111111111111111111111 APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE � DATE i i 11 - - v - • - - a wszv- vf4wj 6' !/ % Z - l 'y / v CONDITION(S): EH 23 046 (Revised 9/11/96) Page 3 1-1