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SAN JOAQUIN COUNTY PUBLIC NEALTH SERVICES <br /> ENVIRONMENTAL BEALTHD ON <br /> APPLICA77ON FOR UNDERGROUND STORAGE TANK CLOSURE P ° ' T <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHAOED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ZREMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> tADDRESS <br /> E x -�'q� Q2�?j PROJECT CONTACT 3 TELEPHONE # f <br /> F FACILITY NAME PHONE <br /> C �� �t tt 4-T0� � i A <br /> I Vs� t-'C <br /> L GROSS STREET Ay/r--t4 <br /> I r��+45vI ! j ' <br /> T OWNER/OPERATOR <br /> PHONE <br /> C CONTRACTOR NAMEKr'%/ t <br /> 0 !''�tt'� / PHONE # <br /> jAH CONTRACTOR ADDRESS IMN"tI�' CA LYC # �® CLASS G.� <br /> T <br /> R INSURER WORK.COIP 9 <br /> C + FIRE DISTRICT 41'( �lTOC �OM PERMIT # <br /> D LABORATORY NAMECOUNTY zog A, PHONE a (p ; r�r—'1 <br /> SAMPLING FIRM <br /> j it1!!I!!!!lltKtt iiI111 !t TANK rkIZE CHMIICALs STOREDaENTLY <br /> 39- /PREVIOUSLY DATE UST INSTALLED <br /> 39- _ <br /> 39- <br /> 39--- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> APPROVED 7APPROVED WITH CONDITICH(S) DISAPPROVED <br /> .SEE CONDITIONS 2ELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME ,Cr G _ DATE <br /> ..�.� - <br /> 1lt111l11111!!!111il11111l1fillllifil!!!11lt11tlt111liitiil!!l!ltlltt!llflltll!!t1l1t!l11ii1l1111111t1!!1!!illiilli1tt11t1i11 <br /> PLICANT MUST PERFORM ALL WORK IN ACCMANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNCR OR LICENSED AGENT'S SIGNATURE CERTIFIES TiiE FOLLDWYNG: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECAME <br /> JECT TO 'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 1tlCER72FY THAT IN THE PERF CE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> PENSATION LAWS OF CAL IA." <br /> L ILat� <br /> FPLICANT'S SIGNATURE: TITLE li DATE I <br /> CfDrrlON l (� ��, p .s •t"�.- . <br /> 3 _ .S c z._ t< <br /> 17-3 0" (Revised 4/1!/46) Page 3 <br /> I <br /> E d LEVO 1E9 916 'ON Xdd DNIMME NOSNOHV Wb 50 : 11 IlHZ L6-� -dHS <br />