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ill A <br /> SAN JOAQUIN COUNTY PUBLIC REA'LTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 11 <br /> APPLICATION FOR UNDERGROUND STORAGE XA,NK,CLOSURE PERMIT <br /> INE PERMIT FOR P5RMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNOERGRmm0AAZARDCUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.'EINDLCATE PERMIT TYPE BELOW: � <br /> y REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE 9 1.10'1 C� "(� PROJECT CONTACT & TELEPHONE.'I*mr <br /> F FACILITY NAME ( be,4mma re pNrc, r� it PHONE � <br /> A <br /> C ADDRESS ill-50 $F�h&Kl, Ljt44� ii <br /> I - ` � <br /> L 02055 STREET fri3 Z� I <br /> T OWNER/OPERATOR :C PHONE <br /> Y , �' !r y X20) S Zqr�6 71 <br /> C CCNTRAC T CR NAME SF1';CC? ;1 PHONE # .(209) 524-9653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. Mcdesto, CA 95351 L!C 449864 CLASS A,3,C61/D40 t <br /> T <br /> R INSURER CalC;omp Ir15urance C Mrlany WORK-CCMP.: W964137662 <br /> A <br /> CT . tt -- �r �c ��aLxc�OM1ra ^? , PERMITF[Re DLSTRICT <br /> f <br /> a LABORATORY NAME Geoanalytical Taab I COUNTY gt�n;slates j I PHONE 209} 572-0900 <br /> x ' <br /> SAMPLING FTRM Geoanalytical Tab II PHONE (209) 572-0900 <br /> 111111111111111iI1{1{111!11111 <br /> I TANK I0 `. TANK SIZE CHEM ICALS�STORED11YRi:NTLY/PRE'/ICUSLY DATE UST INSTALLED .I <br /> 39- — on coa I,zr de<� Gesso „4� <br /> A 39- i <br /> N 39- <br /> K 39- i <br /> 39- <br /> 39- !j. <br /> P IIllllilllllillll[1111I[I11 {[ II IIII Ifill IIII 1 1 1111111 1111iI1111111If111[11111111111111 i I I I!I I1III11111111111111111 <br /> L _ APPROVEDDAPPROVED WITH CONOITION(S) DISAPPROVED <br /> A ( E_ CONDITIONS 3ELCW AND/CR ON'ATTACHMENT) <br /> PLAN .REVIEWER'S NAMEDATE f71 <br /> 1111111 fill 111111{111{{{{{{{Illlll{II11 11 II1111111I111{11{1111!{1[11{{{{{11111{{Illi{{1{1lII111I11111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN =NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNAT9RE CERTIFIES THE FCLLOWINGI "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EI4PtOY AHY ,PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFCRNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTirY THAT iN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI <br /> t� ?�wx�n -f�-SFS <br /> APPLICANT'S SIGNATURE: TITL` OATI <br /> CONDITION(S): Underground Service Alert will be contacted"at least 48 hours prior to start <br /> I of e. cavation_ <br /> E Y � <br /> EH 23 046 (Revised 7110/96) Pa <br />