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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUI'N COUNTY <br /> APPLICATION FOR UNDERGROUND STOR-AGE TANK <br /> '01-C)SE)RE PERMIT <br /> OF UNDERGROUND HAZARDOUS WBSTANCES <br /> HISPERM17i FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACEA.VE - INDICATE PERMIT TYPO: <br /> STORAGE TANA--j)UPIPEq Jar)DAYS FROM THI-:t APPROVAL DATE- 00 NOT WRITE IN ANY SK zDAREAS <br /> RU'REGI OVAL FITEMPORARYCLOSURE EJ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> 1 PROJECT CON 'T 10,5fcz <br /> W PHONe# 0 <br /> FACILITY WAME q <br /> CROgg STREET <br /> OVslN R OPO�RATOQ <br /> GO RACTORINFORMATION <br /> - . .1,c. — <br /> CC- RACTORADDRIFSS ff CA LIG-4 GLASS <br /> INSURER %Aff'-RKER GOMP# <br /> PERMIT A <br /> FIRE DISTRICT-5 <br /> .LABORATORY NAME G. P- COUNTY- <br /> WAPLINGFIRM <br /> TANK I'NF-ORMATION INSTALLED <br /> 'PRE TAK PAST) <br /> TANK ID TARR$1 TANK GOPlr�NTS�k <br /> ej <br /> 39- <br /> OtjDANCEWITHSAN JOAQUIN COUNTY ORD(RANCES-STATE LA,NS,FEDERAL LAWS.AND RULES AND <br /> APPLICANr MUST PERFORM:ALL WORK IN AGG N -"f DEPARTMENT- 041NER OR WENS M- AGENTS 84014ATURE CERTIMEEI THE <br /> QATE)N8, <br /> WD PASTI 7�-TA <br /> �--_-4:41- <br /> RF <br /> 'GLILATIgNg Op SAN JOAQUIN GoIJ14TY ENWRONME'TAL HEAL PERMIT I S ISSUED,A Sti-ILL-NO-r WOLOY ANY PERSON IN SUCH <br /> FOMOWNQ 'ICERnF(Ti4ATINTHIE-:PERvoRmAt4CEOF WORK FOR WHICH MIS <br /> CONTRAQTO" HIRING OR-SUBCON7RACTING <br /> A MANNrA A$TO 8MOME SUBJECT TO WORKER'S' <br /> C rJEWSAMON LAWS OF CALIFORNIA <br /> %31GNATUT%E CWF(FIES THE FOLL0VNqNG- ,GFRTj-.y,r"xr 114 THE PERFORMANCE OF THE tAlORK I-Or,IN1110"THIS PERMIT IS 18aUE.D,I SHALL <br /> j�$CMAPENSATIQNLAVYSOF IFORNIA.' <br /> �a4 <br /> EMPLOY PERSONS SUBJECT TO WORKE <br /> DATE <br /> APPLIGANT'8SIGNATURE 1 TITLE <br /> `El/APPROVED WITHCONDITION(S) '0 D18APPROVE"b <br /> 0 APPROVED "j(gF�E CoNbrr,0-N5SELOWANDR)R-ON ATTACI IMENT) 7 1-- <br /> /A <br /> PLAN REV DATE <br /> _ <br /> REViEWVJtS NAME f <br /> -BE-S-usmn7EQTo Eno FOR APPROVAL PRIOR TUCOM MENCING WORK. <br /> ANY t)�VIATIONS FROM THf,9 APF,�L(dTIQN musT <br /> CONDITIONS: <br /> EH230416 (Revired(0130112) 3 <br />