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4 _/ V <br /> 6711 <br /> V , <br /> EIIVIRCKMENTAL HEALTH DIVISION <br /> 1. <br /> APPLICATION FOR UNDERGROUND. TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE CIL ABANDONMENT IN PLACE OF UNDERGRCUND 'HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT WIRES 90 DAYS FRLN THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE `BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> - I <br /> PROJECT CONTACT $ TELEPHONE <br /> EPA SITE S C A D 982 059 # 209. 835 7071 <br /> I <br /> FACILITY NAME M & M ATztomotive A[PHONE # 209 835 7071 <br /> ADDRESS East 10 th St Tracy Ca 9 376 <br /> 4 <br /> CROSS STREET <br /> OWNER/OPERATOR PHONE 0 <br /> Larry Mc Lean & Richard Moe 209 835 7071 <br /> CONTRACTOR NAME A A .A Tank Removal & Demo PHM 931 681c) <br /> i <br /> CONTRACTOR ADORESS4 <br /> 900 N H 99 206 Stki3 CA LIC #243520 CLASS A <br /> INSURER S,,tat@ d WORK.COMP.t66 851, '-'90 <br /> FIRE DISTRICT Tracy <br /> PERMIT #. <br /> i LAUCRATORY MAKE Sequoik Analytical. PHONE #510 686 9066 <br /> ,AMPLING FIRM Tank Protect J PHONE # 1 800 523. 8088 <br /> - 111111111111111 111111l1i111111 <br /> TANK iD T SIZE CH ICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- �5 - 5� <br /> 39- z�s y G.2 285 a 0&A; <br /> 39- <br />} i 39- <br /> 39. <br /> I 39- <br /> 39- <br /> !i1!!11111111111111111111111111l11111111l11ll11111111l111111l111111111111111111fl1l11111111l1111111111111illlli11111 <br /> 1 11111 <br /> APPROVED _ APPROVED WITH CONOITION(S) DISAPPROVED <br /> 4 (SEE ATTACHMENT WITH CONDITIONS) <br /> PLAN REVIEWERS NAME DATE <br /> 1111111!1111111111111111111111111111111111111.1111111 luffil111111111111111111111111111111111111111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAI! JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY TRAT 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 BECAME <br /> 9 <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF' CALIFORNIA.WL CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br />` APPLICANT'S SIGNATURE: _ ILS' y TITLE DATE Cc—. P_1 <br /> 4, <br /> 23 046 (Rev 2/8/91) ft Pag¢ 3 <br />