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�J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PER111ZTT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL 0 TE- 00 NOT WRITE IH ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CA 8210626 9-32-* PROJECT CONTACT & TELEPHONE I MAkRSC.£ -36,,15o Zoll�q Z-'Z07S <br /> SHARD E I PHONE # <br /> F FACILITY NAMED.L-A . �£fErt5E-Pt5r. DEPOrSAaJOAQu14 stTE (7-09)'IbZ-2075 <br /> A <br /> C ADDRESS 7007 E , ont -+P• t-A-inmor, CA 45330 <br /> I <br /> L CROSS STREET = S <br /> PHONE ONE .! <br /> T OWNER/OPERATOR U.5. Gov' <br /> T 204� q$2-2a 7$ <br /> v <br /> C CONTRACTOR NAMECA L YN C PHONE 0 C707)446-79 ,5 c <br /> 0 ZOHo EA,509`f RA. 97"1 <br /> N CONTRACTOR ADDRESS CA 4568-1 CA LIC (pS7?S4 CLASS A $ As3 HAS <br /> T WORK.CCMP.A N w �-($'00 g(,,-C) 2- <br /> R INSURER �.I�.Tg,2RtL� ALS �- <br /> A <br /> C FIRE DISTRICT PERMIT 2 <br /> T (� I ' ^; (-;�- <br /> 0 LABORATORY NAME �j;r ^ 3 caUNTY PHONE S / r'1• C1: <br /> , (,^ - s <br /> R PHONE S <br /> SAMPLING FIRM <br /> 1111t11(It111ItIII1Iit1111 <br /> � TAANKNK ID 0 TANK SIZE CHEMICALS STORED CURREHTLY/PREVIOUSLY DATE U57 INSTALLED <br /> 39- I � ) �9+Q I l/Y" T`i✓� ?D <br /> T 39- R _ �(� r r [ 7U <br /> A 39- f-Z Z / _ r 1 U 10 <br /> K 39- �f5 ._lZ S21�_ «t 1 nn't t Azo <br /> 9l 1 111/ <br /> 11111 11 f 11 I <br /> P <br /> fill <br /> 1"3sr l <br /> L APPROVED <br /> /, PROM WITH CNDITION(S) DISAPPROVED <br /> A SEE CCONOITIONS BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAME r/i1 /`s DATE <br /> ' II11111I1I111111IItIIIItII11III1tIII11ItI1IIIItI1tItIlltIllllltlIIIItI111tIIIlIIII11tIlII11tIII1tIIitIIIIttI1tI11IIlIlltlttll. <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LASTS, AND RULES AND REGULATIONS OF <br /> SAN JOAGUIN COUNTY 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 PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 111 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> CCKpENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �y TITLE ®fR(jIEc7- AAAIA4ek DATE L .2B Q <br /> /98 <br /> CONDITION(S): <br /> J•, <br /> C 1�l � �/( G K c "'!4 116/n( L l ( `•" �� i <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />