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ONov 04 2011 9:01RM L HSERJET FRX P.2 <br /> ENVIRONMENTAL HLTH. DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PeOW FOR PERMANENTREMPORARY CLOSURE IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE S <br /> STORAQE TANKS)WIRES 184 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHARD ALAS. INDICATE <br /> REMOVAL ® TEMPORARY CLOSURE ❑CLOSURE IN PLACE <br /> 'FAGIL R7 INFQ TION <br /> EPA SM# PROJECT CONTACT L�► .-2 = <br /> FACILITY UM L690 FAULIMPp{ONEO �... <br /> ADDRESS 2$ W N#olW f <br /> s smamm, LA 2120 <br /> S ! <br /> OPERATOR <br /> CO C't'®Ft-INFO TI <br /> CTOR CA LIC# gas <br /> R <br /> EMPMRCOM" <br /> PERMIT# <br /> LimIMYNRME VAIs LA6-S Q Ib E# <br /> PI.iNCiF�iut Ns_. PHONI # <br /> TANK INFORMATION <br /> TANK IO# T TANK CONTENTS PRESENT AND PASn DATE'INSTALIM <br /> 39- <br /> .39- <br /> 39- <br /> 39- <br /> 39- <br /> APKICAW MUST PORPORM ALL WOfW IN ACCOWANICE WITM SAN JOAMM OOUNTY ORDIWACES.STATE LAWS..FEDERAL LAWi:4 <br /> REGMATI OF SW JOKMIN COtNNTY ENVIRONWEINTAL HEALTH DEPARTl4EMf'i'. OWNER OR UCENSW AGENT'S SIGNATU <br /> FOLLOWM�: 9 CERTIFY THAT IN THE PER OF TI#E FOR WHICH THIS IS ISSU A I SMALL.Nor EPoIP"AN <br /> A Ay4NNER AS TO E SUBJECT TO WO SATtON LAIN3 OF CALIFORNIA.- CANTRAGTOR9 HYiINCi Cfi <br /> SIGNATURE CERTIFIES THE FOLLOWtft 1 CERt7FYTHAT THE NCE OF THE WOW FOR WHICx1 THIS PERW IS ISSUED. <br /> EAVLOY PERSONS SUBJECT To C Ti WS OF NIA.' <br /> APPIdO:PdVi'S SIGNATURE s TITLE V—^ 4i- -DATEll !7:W <br /> 0 APPROVED Q APPROVED WITH ®MON(S) ® DISAPPROVED <br /> (SLE CONDITIONS SR,0W ANWR ON ATTAC NT) <br /> PLAN REMEWE"NAW DATE <br /> ANY DEVIA TIM APPLICATION MUST IM 8UWTM TO EHD FOR APPROVAL <br /> CONDITIONS: <br /> EH 23 046 (Ravisa.81ll11) 3 <br />