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F A C I L I T Y C 0 N T R A C T 0 R 0 RECEIVED MAY 2 81996 ENVIRONMENTAL HEALTH DIVISION ENVIRONMENTAL HEAL T` PERMIT / SERVIGL_S APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE EPA SITE # e FACILITY NAME ADDRESS CROSS STREET ZIb G OWNER/OPERATOR a t� 1'Q wta i CONTRACTOR NAME CONTRACTOR ADDRESS SLE INSURER c- - . _ _ _ FIRE DISTRICT LABORATORY NAME Wx P L A PROJECT CONTACT & TELEPHONE # �'v(_ o cl rtog v` PHONE # ® _ q-77 - 3 ( 1 I PHONE # tic. 2-0C1^ S 3 31 E) I %4qtr-` N PHONE #91(o- 1 (o 37 LhW . . S CA LIC # CLASS A Z � �AaoJt .sir moi/: WORK.COMP.# LU)g CI.S - (.'Sl �3 l i l l l! 11 C 4111v4u<r-cAtA o r TANK SIZE CHEMICALS S ll b, LTCJo .+ I[9� no D � DU n .ti ripe DOL) PERMIT # # `Ito -7S3-4560 PHONE # 9 j/_ _ 73,-7 _�l-7® ENTLY/PREVIOUSY DATE UST INSTALLED APPROVED WITH CONOITION(S) DISAPPROVED �i _ ATTACHMENT WITH CONDITIONS) N N PLAN REVIEWERS NAME 7 L7Li4 � DATE , & ( III 11111111111 liiiiiiiiiiiiiiiiiiiiillifillilI 111111111111111111 111111111 if] (iTITUM APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: 7 TITLE 090-142-1- L71)2 �ATE 7V�il�,.� J . 3 v l b 3 dry ,u fX f 10 Lq) )�w' ; f amu.`.`. 0' f (xV-.L- 4-5 (-"--ri 7) 0 EH 23 046 (Revised 4/2'X6941/, '• � 'ill �� ` ` SAMPLING FIRM TANK ID 39- ' —1A11.7-5 T 39- 'TA 11 7,5 A 39- TA it X, N 39- TA i i ;t�5 K 39- 39- Wx P L A PROJECT CONTACT & TELEPHONE # �'v(_ o cl rtog v` PHONE # ® _ q-77 - 3 ( 1 I PHONE # tic. 2-0C1^ S 3 31 E) I %4qtr-` N PHONE #91(o- 1 (o 37 LhW . . S CA LIC # CLASS A Z � �AaoJt .sir moi/: WORK.COMP.# LU)g CI.S - (.'Sl �3 l i l l l! 11 C 4111v4u<r-cAtA o r TANK SIZE CHEMICALS S ll b, LTCJo .+ I[9� no D � DU n .ti ripe DOL) PERMIT # # `Ito -7S3-4560 PHONE # 9 j/_ _ 73,-7 _�l-7® ENTLY/PREVIOUSY DATE UST INSTALLED APPROVED WITH CONOITION(S) DISAPPROVED �i _ ATTACHMENT WITH CONDITIONS) N N PLAN REVIEWERS NAME 7 L7Li4 � DATE , & ( III 11111111111 liiiiiiiiiiiiiiiiiiiiillifillilI 111111111111111111 111111111 if] (iTITUM APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: 7 TITLE 090-142-1- L71)2 �ATE 7V�il�,.� J . 3 v l b 3 dry ,u fX f 10 Lq) )�w' ; f amu.`.`. 0' f (xV-.L- 4-5 (-"--ri 7) 0 EH 23 046 (Revised 4/2'X6941/, '• � 'ill �� ` `