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10/17/2000 09:00 209468 3 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANY(S)E%p1P,ES BD DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE; <br /> 9 REMOVAL ❑ TEMPORARY CLOSURE —_CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA97T T, PROJ£CTCONTACTWRK PHONE# <br /> 995 oop Won <br /> FACT ITV E PACIFIC A ARCO # <br /> ADDRESS 6425 PAClFIC AVE, STQ4;KTQpi, <br /> OSS STREET 0011121 M <br /> OWNER OPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAMEW.A_ PHONEN <br /> CCWTAACTORADDRE9 6940 CA LIC#A4557 LA <br /> INSURER W RKER OMPtt . <br /> FIRE DI RI IY# " <br /> LABORA7 Ry NAME O NTY PHONE# <br /> SAMPLING FIRM PHONE N <br /> TANK INFORMATION <br /> YANK td# TANK SIZE TANK CONTENT RESENT 8 PAST) DATE INSTALLED <br /> 39- GASQLTNF <br /> 39- 10,000 <br /> 39- 10,000 <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICRNSIO 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 /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF C4LIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTGTES <br /> THE FOLLOWING: Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S CONPGNSATION LAWS OP CALIFCRWUI' <br /> APPLICANTSSIGNATURE TITLE 014NER OATS (� <br /> O APPROVED ❑APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED OB/79/uB7 Page a <br />