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• <br /> RECEIVED <br /> MAY 2 81996 <br /> ENVIRONMENTAL HEALTH DIVISION /ENVIRONMENTAL <br /> PERMIT / SERVIC E:: <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PE �/ <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDE/RGROUNDDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED A*- INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLO RE IN PLACE <br /> EPA SITE #GAS g3op�33(o3 PROJECT CONTACT & TELEPHONE # L}}r]Q��] 'l S�3 -32`I-- 7 <br /> F FACILITY NAME ,SIJsn�cvl PHONE .` 4-7-7 �3I <br /> C ADDRESS ��-.1CD E, OAwlAAL-_ LJ� GtC --r*n�lS� 1O <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> Y �'��cM A iz, =L�L 2cri S�3 3-3 Z(1-7 <br /> C CONTRACTOR NAME tQ + E �� C— <br /> y PHONE C{E <br /> N CONTRACTOR ADDRESS 3 1(2 CA L)�: CA LIC S CLASS A _ Z <br /> R INSURER WORK-COMP # ��GlC'—(6S l 3�-0 <br /> A <br /> F RE DISTRICT �r PERMIT # <br /> ABORATDRY NAME - t Lsy Zvi U� PHONE <br /> SAMPLING FIRM 4�C,PLA JU t -�� �1�jQaQ ��� PHONE <br /> l III I11l11 <br /> TANK II I IIlI !!1I <br /> TANK ID # ANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- i Z L i 0 r <br /> 19 <br /> T 39- 2. o� fbao U►.D u�.1D -�ft�a <br /> A 39- 12 S 3 A L4 <br /> N 39- I t Z G'A- r V4)-o " <br /> K 39- <br /> 39- i <br /> 39- <br /> 1!1! ! 1 I! l 1 l 1 II 1 11 1 1111 it <br /> P <br /> L APP ED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( E ATTACHMENT WITH CONDITIONS) / <br /> N PLAN REVIEWERS NAME DATE <br /> I!l111lI11IlIlIllII] Ill!! <br /> APPLICANT MUST PERFORM ALL RK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC LTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING. "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMP SATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. <br /> "I CERTIFY THAT IN THE RFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION TANS OF IFORN1; <br /> 26 APPLICANT'S SIGNATU TITLE DATE S-23 <br /> zz. /�z: /'f,rc.c� Gc./j.�c- �w/�1< �-,, � � �-,,,�,.�- h�,�•G.Y � �. �r zw <br /> . .3 _ GI -1t -r I ct C <br /> S,c� Q f �-- <br /> EH 23 446 CRevts 4/g6/94) ` i �� / cPa9p 3 Com `7 / v <br />