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12/16/2004 15:18 2694683433 FIFTH FLOOR PAGE 04 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICA'T'ION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> Trus PERMIT FOR PERMMENTMWORARY CLOSURE Oft ABME)ONMENT IN PLACE OF U NOERGRWWD HAZAR0WS SUBSTANCES <br /> STORAGE TAN(q8)EXPIRES 913 BAYS FROM 174E APPROVAL DATE. DO NOT WRITE IN ANY SKA13£0 AREAS. INUTCATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION ' <br /> EPA SITE,:G A•L 02 3 P=MCI cONTAcr F HOxe# s <br /> FACILITY NAME L T^F~(N R rC� P>ie3hlE i! <br /> ADDRESS W C-2L..flf"'a ' a.0 GR CA vo&_a <br /> CROSS ME baetal^A P.&C R445 <br /> NEROPERATOR DI�� PNONE# Yl CalQ <br /> CONTRACTOR INFORMATION <br /> GpN7iiACTOR NAME L t G/f A�i� 3 P10.[ GeOayr PRONE# 45'4?7 Btnis/ <br /> CONTRACTOR ADDRES45 FW 2T i CA LIC 4 ho 3 a-Am R( rl A�- <br /> WSURER $ Cd A O P# i ! <br /> IrVWDISTRICT Pt=RMr'I'0 Q 4 <br /> (A80RATURY NAME COUNTY <br /> SAMPLING,FIRM CAM p PHONE M G <br /> TANK INFORMATION <br /> TANK 10 X TANK SIZE TANK CONTENTS PRESENT DATE iNSYALt ED <br /> 39- I r vc i 1 ci k o <br /> 39- l barrZ t qo <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> APPUQWT MUST PERFCMA AM WORK IN AOOUPd"CE VM"SAH JOAOUIN CQUFM ORDINANCES.STATES LAWS.FERAL LAW&AND RULES AND <br /> FtEGUI.AitONS OF SAN JOACKAN COUNTY PUBLIC HrALTH ES OWNER OA L10ENSM AGEWS alWATURE CERTIFIES TA4F FOLLOMiq 7 <br /> Ct'I4gTWpY THAT IN THE PERFORMANCE OF THU WOW FOR 5 pEpAmy 15 e*s=.I Stall NoT ANY PER9W W SUCH A>41MMUR AS <br /> TO 9FAOFAE SLtaJECT To WOin[ERS OOlAPFPTSATI�1 lJti ODNTRACTOR•S KLRUW OR SUBCONTRAOTM SIGNATURR CJ30*WS <br /> TIU FOLLOWINQ'I CBRTtRY YMAY W4 RFOFtMAH W013K fOR Mtm"YMs PERNwr t819S oo.f&NALL gmFLOY DERSONS SUB�EGT YO <br /> WORKER'S COMPENSATPH LAWS Of f <br /> S . c� <br /> PJVUGA14M 5t+3NATURE 'TITLE F'1rir)C ianT& IL 6 d� <br /> E3FPLAMNFRMeV:SEW&WSKAM VED APPROVED WITH CONDITiON(S) ❑ DISAPPROVED <br /> �CQFWnQNS BELOW ANDIOR ON AT'TAGI6ITo M <br /> ATIONS FROM THIS 14PPL.iCATION MIlST BE stmmrmo TR ENO FoR APF'ROVAI OIIIMENC <br /> CONDITIONS: <br /> 1RH 13 046(REViS01IBt13M991 Pape S <br />