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Jul 31 02 07: 13p K. E Curtis Construction 206234-2411 p. 7 <br /> CC>uN11' PUBLIC l-I L-AI_l H SEPVIr.F <br /> [-_NVIRUNML-NTAL HEAL] H DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> 11401i 1(1121'1`RMANE;N7/ILRAI'()IIAl L tillltEi0fAItAIJI),INMI-N1INPI.At-V UI UNIi(_I-A1141)i1AZAHDolSUIISIAIJCE:, <br /> Iu l;l I Alvi I-XPIRES 90 DAYS FI?i THE All 1a)VAI !l If 1)C)i WRFII- IN ANY SHADf_I)ARF.A:; INDICATF PCRii TYI•I <br /> i <br /> REMOVAL 0 TEMPORARY CI.OSURF I-1 CLOSURE IN I'I_ACf <br /> FACILITY INFORMATION <br /> EPA SITE N PROJECT CONTACT PHONEN <br /> (AGILITY NA <br /> A7E � PHONE q <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR S PHONE# <br /> ' CONTRACTOR INFORMATION <br /> CONTRACTOR NAME � <br /> PHONE# <br /> CONTRACTOR ADDRESS <br /> - Q <br /> CA LIC# CLASS a/ <br /> INSURER � WORKER COMP �- � <br /> 1 FIRE DISTRICT PERMIT# <br /> II LABORATORY NAME <br /> { SAMPLING FIRM COUNTY PHONE# <br /> PHONE k <br /> TANK INFORMATION <br /> TANK ID>~ TANK SIZE TANK CONTENTS PRESENT 6 PAST <br /> 39_ DATE INSTALLED <br /> 39- C3p D <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- P <br /> 39- p a <br /> 39- <br /> 39- I <br /> ' APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL LAWS,AND RLp SAND <br /> REGULATIONS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. O'/vl OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 <br /> CERTi 71 IAT IN THE PERFORMAI OF THE WORK FGF.INHICH THIS PER).!IT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECON.E SUBJECT TO M'ORKER S COMPENSATION LAI4S 0-CALI-ORIJW." CO.NTRF CTOR'S HIRING OR SUBCONTRACTING S:GN•1TURE CCR7l ES <br /> THE FOLLOWING' -1 CERTIFY THAT IN THE PCRFORASANCE Cl T:-t_wUz?K FOR v�'H!C:H THIS PERMIT IS ISSUED.I SHALL EMt'LOY PERSOP:S SUS-IECT TO <br /> WORKER'S COMPENSATION LAYS OF CALIFORNIA.- � ` <br /> i <br /> APPLICANT'S SIGNATURE <br /> A TLE_���ic�� <br /> ❑ APPROVED PPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> r' (SEE CONDITIO::S BEL ANGOR ON ATTACHMcld)) <br /> t I <br /> PIAN REVIEWER'S NAME l - D;aTE I /0 <br /> ANY DEVIATIONS FROM THIS AFF'LICATION Ill i SUGt.51TTEU TO i FOR APPROVAL PR10F:70 COMMENCIN WORK. <br /> CONDI ,{ONS: <br /> _Cj 0i <br /> I <br /> r <br />