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10/17/2000 0,3:00 2094683433 FIFTH FLOOR PACE 03 <br /> SAN JOAQUIN COUNTY PUBLIC l-IEALTR SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORA43E TA14K CLOSURE PERMIT <br /> *IS PERMIT FOR PERMANENT,-rEMPORARY CLQSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STOPAGE TANKS)EXPIPI's5 BO DANE mom_KE APPROVAL DA,7rm DO[•SOT 1WFUTE IN ANY SHADED AREAS. SND ICATI=PI=RSVSST 7YPa <br /> 10 REMOVAL ❑ TEMPORARY CLOSURE _CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> I;FLA 91T PA ECT CONTACT XEKT APf 4on1E# <br /> F t n'Yffl_2AQljL_AVl ARCO <br /> >�HO LO# <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPER= M__R PH N> * <br /> CONTRACTOR INFORMATION <br /> _0304TRAc PHONE N <br /> CQNmcTcR ADDAE$LA240 TREMONI ROAQ_ nTxQN.r4 qqfizo __ lCAL)C#A45,5752 I~ L A <br /> INSURER -SrRvrpsw RK P- OKIft <br /> FIRR D[ 1 # _ <br /> I ASORAT RY NAME PHONE Ak <br /> SAMPLINGFIRM PHONE 4 <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENIT$ RESENT 8 pAsn DATE INSTALLED <br /> ;39- <br /> APPLCWr <br /> - GASOLINEnoo <br /> �- 10,000 GASOTINE <br /> 10.000- <br /> - <br /> i <br /> AtfST PERFORM ALL WCAK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIWANCES,STATE LAWS FEDERAL LAWS AND RULES AND <br /> REGULA71pNS OF 3"JOAQUIN COUNTY PUBLIC HEALTM SERVICES OWNER OR LICENSED AGENT'$ SIGNATURE CERTIFIES THE FCUOWING -1 <br /> CERTIFY THAT N THE PIiRFOF%ANLL'OF THE WgQRKK FOR WHICH THS PERMIT IS ISSUEC,I SWU.L NOT EMPLOY ANY PERSON IN SUCH A MANNER A§ <br /> TO BECOME SLKJEC7 TO WORxI:R 9 COlIIPSNSA1i0N LAWS OF CALIFORNIA.' CONTRACTOR'S HIAWG OR$UBCIYr AATIP4$IGNIATURE CE.RTtFlES <br /> THE FOLLOWING 'I CERTIFY yhAT IIV TFIE f ERIwORMANCE OF THE WORK FOR WKCH THIS PgRM f 4 ISSUED,K SHALL EMPLOY PERSONS SUBJECT TO <br /> WVRVMWSr-,C Z"4A7XMLAWSOPCALIFOlV%k' <br /> APPLICANIrSSIGNATURE TMEOWNER [}ATIr <br /> 0 APPROVED ❑ APPROVED W)TH CONDITION(S) L-7 DISAPPROVED <br /> (SEE OONdITIONS BELOW ANlalaR C71+1 ATTACHMENT)?4Ah1 d�VIE'NER'S";,4F,. IDA-re. <br /> ANY DEVIATIONS FROM THIS APPLICATK7N MUST BE SUBMITTED TO EHD FOR APPRIOVAL PRIOlt3n Q2MMl!NCjNGORK <br /> CONDITIONS: <br /> EH 23 046(REVISE—canwgq) P"43 <br />