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5-27-04; 8-43AM; 0 ;925 551 7888 Y# 25/ 34 <br /> 03/05/2004 13:59 2094683433 FIFTH FLOOR PAGE 07 <br /> SAN JOAQUINi COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PI~RMIT <br /> 'PHIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMBNTIN PLACE OF UMERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIRES 90 DAYS FROM THIS APPROVAL DATE: DO NOT WRrM IN ANYSHADED AREAS. INDICATE PERMIT TYPE; <br /> j XREMOVAL ❑ TEMPORARY CLOSURE 17 CLOSURE—IN PLACE <br /> I <br /> FACILITY INFORMATION <br /> EPA SITE E PROJE CONTACT C-D-Y l�St & PHONE# 619,. (�' <br /> FACILITYNAME b� // 6L-a PHON 2w1, I - II S <br /> ADDRESS A.+l oZ lif/L vt%% �CA-t-ot4,C4 <br /> CROSS MSET o2 c <br /> OWNER oPTo12PHONE M aS <br /> CONTRACTOR INFORMATION <br /> -R NAME <br /> ` <br /> .fCNTRACTOO <br /> CONTRACTOR ADDRESS CA LIC Z® CLASS <br /> INS R WORKERCO P-- <br /> H <br /> DISTRICT PERMIT# <br /> LABORATORYNAME (' Cal--, A tJr4 I CQ PHONE# <br /> SAMPUNG FIRM ah/ IFHDN # <br /> TANK INFORMATION <br /> TANK IG: -TANKSIZE I TANK CONTENTS PRESENT B, PAS DATE INSTALLED <br /> 39-Of t D gL. <br /> 39- € <br /> 39- <br /> 39- <br /> F <br /> 39— r <br /> aPPucANr Musr PERFlORN ALL wOluc IN ACCdROANCfi'WITti SAN JOA4UIN coUtay OROINA.VCE6,srA•r8 Laws.FEDERAL LAwS.ANO RULES AND <br /> AGOULATIONNS OF SAN JOACIVIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING, 9 <br /> CERTIFY THAT IN THE PERFOPA"CH OF THE WORK FOR WHICH Tffi$PERMIT IS ISSVELI.I SHALL IVO£EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO 90009E SU6.IECT 1ti0 WORKER'S COWGIMATION LAWS OF CALIFORNIA.- COWPA4TOrl <br /> MIRING OR SUBCONTRACTING SIGNATVRG CERTIFIES <br /> THE FOLLOWING-1 CERTIFY THAT IN THE PERFORMANCE of THE WORK FOR WKCH TICS PsMaT IS ISSUED,I SHALL EMPj OY PERSONS SUSJC^CT To <br /> WORKERV COMPENSATION LAWS OF FORNIA: <br /> APPLICANT'S SIGNATURE TITLE 1 DATE/O <br /> ❑APPROVED 10 APPROVED W)TH CONDITIONS) ❑ DISAPPROVED a <br /> (SEE CONOITIONS BELOW ANINOR COATrACHMENT) C <br /> FIAM1I REVIEWER'S NAME e+,�,_ DATE3 �3 <br /> ANY DEVIATIONS FROM TH12 APPLICATION MUST 13E SUBMtTTE)TO OlDFORAIPPROVAL.PRIORTO CO&jr4ENGtNG WORK <br /> � CONDITIONS: � <br /> EH 23 046(REVISED 08N 3189) Page 3 M <br />