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SAN '1AQUIN COUNTY PUBLIC HEALT' ' ERVICES <br />*ENVIRONMENTAL HEALTH DIV JN <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />® REMOVAL P%P'NC�.' ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />AtSp_ <br />CONTRACTOR INFORMATION <br />FACILITY INFORMATION <br />I PHONE# • S¢�"•.�Y�(C7 <br />EPA SITE # GCO23Z <br />PROJECT CONTACT 8AhQ L► 1INkjQr�_0�ANMPIA <br />PHONE# 2,0 <br />FACILITY NAME <br />Cy41i V4,A5PA I <br />PHONE #2rni 'C)4 -S • I(p3 �c <br />ADDRESS <br />COUNTY PHONE # 41 S -3G+ .9 (prx7 <br />SAMPLING FIRM 0.RMj5RI A Et4 V I ON r AaWT7}-L- <br />CROSS STREET <br />12, 000 <br />12ZG . ut lL,. <br />OWNER OPERATOR PZ�N�O <br />J GPrI� EPfOs <br />PHONE # 2.�t • �i{'`c3 �1tio3� <br />CONTRACTOR INFORMATION <br />CONTRACTORNAME WGI\LT5T- Cot—AST. <br />I PHONE# • S¢�"•.�Y�(C7 <br />CONTRACTOR ADDRESS . PO- 3 <br />CA LIC # CLASS <br />INSURER \ I Iy IDE:M N 1 ;t.ISvR . <br />WORKER COMP# JPO 11 iO.40(o O <br />FIRE DISTRICT Gid OF '5r0C-j:=-M V, <br />PERMIT# IfA 0G,��fs5 <br />LABORATORY NAME SEW,V 01A —^N AL . Lick f!) <br />COUNTY PHONE # 41 S -3G+ .9 (prx7 <br />SAMPLING FIRM 0.RMj5RI A Et4 V I ON r AaWT7}-L- <br />PHONE # 25 - d) l7 12 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 <br />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 <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIAP% <br />APPLICANTS SIGNATURE (X-6-4-(Aib '(- � TITLE ��J2 ac t DATE /,? -X7 4%47 <br />❑ APPROVED .APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME i DATE I:j � � <br />ANY DEVIATIONS FROM THIS APPLICATION MUST B41 MITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />n u J CONDITIONS: <br />08/13/99) 1 1 Page <br />TANK INFORMATION <br />TANK ID #TANK <br />SIZE <br />TANK CONTENTS PRESENT & PAST <br />DATE INSTALLED <br />39-0002�Jt148allgg. <br />(2, poo <br />Purr . UtSL . <br />05 <br />39- t� .05 <br />12, 000 <br />12ZG . ut lL,. <br />39- n •p(o <br />S <br />UNAL- <br />39- — <br />39- <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND <br />REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 <br />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 <br />TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIAP% <br />APPLICANTS SIGNATURE (X-6-4-(Aib '(- � TITLE ��J2 ac t DATE /,? -X7 4%47 <br />❑ APPROVED .APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME i DATE I:j � � <br />ANY DEVIATIONS FROM THIS APPLICATION MUST B41 MITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />n u J CONDITIONS: <br />08/13/99) 1 1 Page <br />