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Jul 01 03 11:31a TAIT Environmental System (9161 58-1011 p.3 <br />06/30/2003 22:06 4683433 FIFTH FLOOR 0 MAGE 02 <br />SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PBRhIIT FOR PERMANENTJTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF 7.A <br />UNDERGROUND HARDOUS SUBSTANCES <br />STORAG9 IT <br />EKPIRES 90 GAYS FROM THE APPROVAL GATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />REMOVAL/(Qf+,11}{,E'yk(�Ad_TEMPQRARY CLOSURE 0 CLOSURE IN PLACE <br />TANK INFORMATION <br />APPLICANT <br />FACII-17Y INFORMATION <br />EPA SITE T <br />PROJECT ONTA T ti.1 PZ G J-! d tt PH NER `1 <br />FACILITYN E C <br />PHONE• <br />ADDRESS r;Zl 5 . <br />�SRnf ,T71C�1LL1+1 <br />CROSS STREET <br />FIRE 1 T <br />OWNER OPERATOR <br />Z-� O <br />TANK INFORMATION <br />APPLICANT <br />CONTRACTOR, INFORMATION <br />NTRACTORNAME TA./ -F tc-L_V <br />39- <br />9-39- <br />CONTRACTOR AOR <br />U D I i _ CA LICIT CLASS ( / L' <br />INSURER , �(,%i = - �C 1-! A F <br />u l 'T <br />WORKER CgMP-- <br />FIRE 1 T <br />PERMIT a , <br />BORATORYNAME P 7 <br />COUNTY PHONEtl < •I <br />SAMPLWGFIRM <br />— <br />PHONE ► '— <br />TANK INFORMATION <br />APPLICANT <br />TANK 10 ri TANK SI T NT PRESENT d PAT TE INSTALLED <br />39- QaL. API)k P0-r.--U&LLft5- <br />39- <br />9-39- <br />39- <br />39- <br />39- <br />39- <br />39-39- <br />139. <br />APPLICANT MUST PERFORM ALL WORK IN ACCOROANCE WITH SAN JOAQUIN COUNTY OROINANCHS, STATE TAWS, FEDERAL LAWS. ANO RULES ANO <br />REOULAT*NS OF SAN JOAOLAN COUNTY PUBLIC HEALTH SERVICES, OWNER OR LICBNSEO AGENTS SIGNATURE CERTIFIES THE FOLLOWING 1 <br />CERTITY THAT IN THE PERFORMANCE OF THE W ORW FOR WHICH THIS PERMIT IS ISSVEO. I SHALL NOT EMPLOY ANY PER10N N SUCH A MANNER AS <br />TO BECOME SUEIECT TO WORKER S COMPENSATION LAWS OF CALIFORNIA' CONTRACTORS NRR10 OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING' -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH YH3 PERA7T IS ISSUEO.I SHALL EMPLOY PERSONS SUOJECT YO <br />WORKtWS COMPENSATION LAWS OF CALIFORNIA. - <br />APPLICANTS SIGNATURE 7 I s.( TITLE �Q�j 2 �6) P f�?C . DATE -111 -In -1 <br />❑ APPROVED O APPROVED WITH CONDITIONS) [ DISAPPROVED <br />(SEC CONDITIONS BELOW ANOIOR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE <br />ANY O6vWTI0Ns FROM THIS APPLICATION MOST BE suawrED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK <br />CONDITIONS: <br />$N 23 0-6 (REVIBSD 08/73179) raga <br />r AS�la/pr�M . i ASFiI!!af <br />e. Rinsate Hauler and permitted Treatment, Storage & Disposal Facility: <br />Hauler Name Phonetl�/D L C7 <br />2 <br />4 <br />t.g.4 <br />I <br />I <br />s .iili r- <br />141 L. <br />