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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE 'TANS CLOSURE PEP241T J <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. EINDICATE PERMIT TYPE BELOW: <br /> iM <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # O� PROJECT CONTACT & TELEPHONE # S <br /> F FACILITY NAME M P E # <br /> A I <br /> C ADDRESS , <br /> I <br /> L f CROSS STREET <br /> T I OWNER/OPERATOR PHONE # _ <br /> Y �� 'I -83 <br /> PHON w I <br /> 1 � <br /> 0 CA LIC # I CLASS <br /> ! N I CONTRACTOR ADDRESS y-7 !D <br /> I WORK.COMP-#�� _(a q - C <br /> R INSURER <br /> A di PERMIT # <br /> C FIRE-DISTRICT C� <br /> T it - # PHONE # i <br /> 0 I LABORATORY NAME nn1 COUNTY S � I ,7'�- Q O <br /> R �, 5AMPL I NG =IRM � 1�r CL` i Cal - -�QC� ��j_ =,n C:. PHONE # aD Q S�'O L D <br /> !I!l111IIIIIIKIIDII1111lIIi11 TANK SIZE CH=_'IICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> l 39- 1 Zf/ i I <br /> A 39- <br /> I N 39- 1 <br /> I <br /> K 39- <br /> I 39- <br /> !liIlllilll 1111I li !II 1 11 11 ! !! ! It!!l ii ii !!! IIl 111 �lift II1i! 11 !! I!! -01 !Ti11i I II ilillill II <br /> F APPROVED SEE C APPROVED LATH CONDITIONS) _ DISAPPROVED <br /> A ( CONDITIONS BELOW AND/OR ON ATTACHMENT) ` <br /> N DATE <br /> PLAN REVIEIIER'S NAME Ei <br /> } 11li!lIIIIi11111IillI ,"HI11lIIIII1111I11!lIIIIIIIIIIIIIIIIIII111111I11illillil!lIIIIIIii!!1llilillllilil!!11l1I1IIIIIIIIII <br /> APPLICANT MUS; PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUHTY ORDIHANGS, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN (CANT ST PER PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN ' <br /> ! THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI7 IS ISSUED, I SHALL NOT 2kPLOY ANY PERSON IN SUCH A MANNER k5 TD BECOME f <br /> i CONTRACTOR'S HIRING,IOR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:1 <br /> SUBJEC" TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> "I C'cRTfFY THAT IN THE PERF MANCE OF THE WORK FOR WHICH THIS PERMIT IS ISESUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFO N A-" f <br /> 3 E <br /> APPLICANT'S SIGNATURE: <br /> TITLE DATE <br /> lq 1` 1� s <br /> AS marl I}4Ti9+P0�� <br /> coNDITION(s): �) p,PG�� �,� �, ,��.�-�/s <br /> . <br /> Gxv+ufir( - - <br /> E� <br /> O� I�4r-rte G64.L <br /> , To �k <br /> Page <br /> EH 23 046 (ReviS&[ 9/11/96) 3 <br /> d <br />