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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ON <br /> APPLICATION FOR UNDERGROUND ORAGE TANK�CLOSURE PERMIT <br /> THE RERMRT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UHDERGRO NND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> y REMOVAL TEMP My CLOSURE <br /> CLOSURE IN PLACE <br /> EPA SITE # •G PROJECT CONTACT it TELEPHONE # <br /> F FACILITY NAME ! �q-y�`+I- <br /> C <br /> ADDRESS / C Q PHONE # z�-w7 G3o3 <br /> L CROSS STREET b <br /> I <br /> T OWN /OPERATOR <br /> Y `�. <br /> 7��19�4t <br /> C CONTRACTOR NAIL �.. I-03 <br /> 0 �. G, PHONE # 7o f y6 .� <br /> N CONTRACTOR ADDRESS Q Q ��. <br /> R !"SURER G+ q J(�,� G LIC #=70 10S`— CLASS G� y� <br /> A � L WORK.COMP.#6?-:>/d/ iE►Zr <br /> C FIRE DISTRICT <br /> r39-- <br /> R� PERMIT # <br /> NAME/'" COUNTY <br /> ow T;h <br /> PHONE #s/d`"/�?�16Z-U <br /> FIRM Vi�� ,��Y��D <br /> 111TANK.. Cl Si2EHENICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> '412 <br /> .,.39- <br /> P IilllTiliiiTffi111 nR�m <br /> L =ROVED WITH CONDITION(S) DISAPPROVEDR�SERViCES <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACH ENT) <br /> N <br /> PLAN REVIEWER'S NAME <br /> DATE <br /> i�ninn�niuinnn�unnnui�i�nmunrunitin�nin�iin�inuinnn�iin�mm�nnnniinurinniuninun <br /> APPLICANT MUST PERFORM ALL WORK IK ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH ICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR ICN THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "! CERTIFY THAT IN THE jt�SMO:IRJOF THE ICH THIS PERMIT IS ISSUED, I SHALL Ei�LOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF <br /> APPLICANT'S SIGNATURE: TITLE DATE 'ZS"f9 <br /> CONDTTION(S): �' - ''[•� <br /> �a..oQwt+.NK �,► � � jb• <br /> EH 23 046 (Revised 9/11/96) Page 3 _"-Z <br />