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05/30/2003 16:36 2094683433 FIFTH FLOOR PAGE 0-; <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR ORARY CLOSURE OR ABANDONMENT IN PLAC5 OHAZARDOUS <br /> STORAGE TANK($)EXPIRES 90 DAYS FROM THE APPROVAL DATE DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br /> 12/REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CA - PROJECT CONTACT k �I PNONE# - Z$Z <br /> PACILITYNAME -7-FItQe,0 SEp - 1 PHONE# Og - - 3Z Z <br /> ADDRESS l <br /> CROSS STREET N , - PHONE ii 20 - LA Z -8L <br /> OW NER OPERATOR ( e �L <br /> CONTRACTOR INFORMATION <br /> •4 � ► S Zvv PHONE# Z - <br /> CONTRACTOR NAME AC c V► � CA LIC# 7 'I CLASS A <br /> CONTRACTOR ADDRESS 1 1 WORKER COMP# l la - O <br /> INSURER �A }1O Z J <br /> FIRE DISTRICT �� O� �'c PERMIT# <br /> COUNTY YQ( PHOPJE# 30- Z <br /> LABORATORY NAME V A `4' A PHONE 4 1 - - <br /> SAMPLING FIRM <br /> TANK INFORMATION DATE INSTALLED <br /> TANK ID ft TANK SIZE TANK CONTENTS PRESENT& PAST <br /> 39- f,o ,5Z i l0 D 111, <br /> 39-5CA"" 2'Z ► / <br /> 39- 1"-;?? l <br /> 1�,N <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT NIUS FPERFORMALN COUNI ATY �N�RONM NT WITH <br /> HEALTHOA0UIN COUNTY DEPAP.TMEN7 OWNER NOR LCENTSED AGENE LAWS, �S RIAGNA7UREL LAWS.ACERT FI ES AND <br /> REGULATIONS 0 SAN J SAN <br /> FOLLOWING; -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN TI <br /> A MA TURF AS TOFIES TORE FOLLUBJECT OW NG:T"IOCERTRIFY THAT COMPENSATION 7HE PER ORMANGE OF THEIWORK FOR WHICH THIS PERM TI SGSSOUEDUBSHALL�EMPLOY <br /> $ <br /> IGNA <br /> PERSONS SUOJECTTO WORKER'S COMPENSATION LAWS OF CALIFORNIA, <br /> APPLICANT'S SIGNATURE <br /> S TITLE JA�10rVS 1�1A DATE G-/-U- <br /> ❑ APPROVED <br /> APPROVED WITH CONDITION(S) El DISAPPROVED <br /> (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> DATE <br /> PLAN REVIEWER'S NAME TTTEO TO <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBM <br /> FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> ' _-,-- <br /> EH 23 045(REVISED 3115/02) Page 3 <br />