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SAN SkQUIN COUNTY PUBLIC HEALTMERVICES ENVIRONMENTAL HEALTH DIVMWON APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ', 41S PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN, PLACE OF UNDERGROUNO HAZARWUS SUBSTANCES STORAGE TANX(S) EXPIRES 90 DAYS FROM THE APPROVAL GATE, 00 NOT WRITE IN AXY SHAM AREAS. INDICATE HITT E ERMITT E REMOVAL 1 0 TEMPORARY CLOSURE 0 CLOSURE IN PLACE FACILITY INFORMATION EPA srrE;s CAS 002572603 1. PROjECT777 Ruth, imnrsi I i PHONM�,!2oo4aaa-a,2on FACILITY NAME Marsili Pro-perty PHONE 4,9 nCa ADDRESS 3212 Woodson Rd. , Ar,,ampo, CA 95220- cRoss.sTREr--T Lower Sacramento Rd, OWNEROpERATOR Ruth Marsili ;;;NE, t., ( 2 0 _)3,6_8 1720 APPLICANT MLST PERFORM ALL WORK IN ACCORDANCE WITH SAN QACIUIN OoLgM ORI)INANCES, STATF. LAWS. FWERAL LAWS, AND RULES AND REG,jtAIONS OF SAN JOACUIN COWM PUaLC HEALTH SERVICES. OWNER OR UC ED AGOMS $4NATURE CERTIFIES THE F4 U04INQ " CERTIFY -�HAT IN THE PERFOftOANCE OF THE WOM( FOR WHICH TMS PERMIT IS ISSUED. I SHALL NOT CLOY ANY PERSON IN UICH A MANNER AS TO SEMS SUBJECT TO WORKVM COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOWS HIRING OR SUSCONTPACTING SMATURE CERTIFIES THE FOLLOWIN11j: I CERTIFY THAT IN THE PERFORMANCE OF THE WCM FOR WHICH THIS PERW IS ISS UM, I SHALL 9An.OY POV004 SAW= TO WOM(MS =VENSATION LAWS OF Ftp APPUCANT'S SIGNATURE TITLE -Contractor _.PA 1215/03 01APPROVED PLAN REVIFEWW3 5V -SD WITH CONDITION(S) CI MM COMMONS BELOW AWM ON ATTACMeM DA"Z"E� 04 ANY omoms mom Tmis AppucAnoN musr sE suommwro am r-oR AppRovAL PA- " TO comeNcNo wo CONDMONS: ................... 0& TANK INFORMATION TANK10 CONTRACTOR INFORMATION CONTRACTOR NAME M TE57pe 39- M, M. CQNTRA�I�RAOORESSP-n- Anx 'IS7 T5CA ndi , rA Qr,9A1- --L4 S A, B RAZ j#4jW,99 1C 5- 3 1NSUff-RA=rj,c&a ntern at'l Spec.Lines woRKER comp* Sta e una, 1671173-02 I FIRgDISTRICT Liberty PeRmrr# 'Upon Approval LAWRAroRyNAMEit7 n y t aC tan 0 I sAmpuNGppm eqAnaTXTTcaT PMOM APPLICANT MLST PERFORM ALL WORK IN ACCORDANCE WITH SAN QACIUIN OoLgM ORI)INANCES, STATF. LAWS. FWERAL LAWS, AND RULES AND REG,jtAIONS OF SAN JOACUIN COWM PUaLC HEALTH SERVICES. OWNER OR UC ED AGOMS $4NATURE CERTIFIES THE F4 U04INQ " CERTIFY -�HAT IN THE PERFOftOANCE OF THE WOM( FOR WHICH TMS PERMIT IS ISSUED. I SHALL NOT CLOY ANY PERSON IN UICH A MANNER AS TO SEMS SUBJECT TO WORKVM COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOWS HIRING OR SUSCONTPACTING SMATURE CERTIFIES THE FOLLOWIN11j: I CERTIFY THAT IN THE PERFORMANCE OF THE WCM FOR WHICH THIS PERW IS ISS UM, I SHALL 9An.OY POV004 SAW= TO WOM(MS =VENSATION LAWS OF Ftp APPUCANT'S SIGNATURE TITLE -Contractor _.PA 1215/03 01APPROVED PLAN REVIFEWW3 5V -SD WITH CONDITION(S) CI MM COMMONS BELOW AWM ON ATTACMeM DA"Z"E� 04 ANY omoms mom Tmis AppucAnoN musr sE suommwro am r-oR AppRovAL PA- " TO comeNcNo wo CONDMONS: ................... 0& TANK INFORMATION TANK10 TANK SIZE TANK CONTENTSf?Wt99NT PA4M DATE wgrALLER . . .... a9- . ..... .................. . 700 U�n�le d Qgis Tinkno= 39- 350 Diesel Fuel 'Unknown 39- 309- 3S - APPLICANT MLST PERFORM ALL WORK IN ACCORDANCE WITH SAN QACIUIN OoLgM ORI)INANCES, STATF. LAWS. FWERAL LAWS, AND RULES AND REG,jtAIONS OF SAN JOACUIN COWM PUaLC HEALTH SERVICES. OWNER OR UC ED AGOMS $4NATURE CERTIFIES THE F4 U04INQ " CERTIFY -�HAT IN THE PERFOftOANCE OF THE WOM( FOR WHICH TMS PERMIT IS ISSUED. I SHALL NOT CLOY ANY PERSON IN UICH A MANNER AS TO SEMS SUBJECT TO WORKVM COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOWS HIRING OR SUSCONTPACTING SMATURE CERTIFIES THE FOLLOWIN11j: I CERTIFY THAT IN THE PERFORMANCE OF THE WCM FOR WHICH THIS PERW IS ISS UM, I SHALL 9An.OY POV004 SAW= TO WOM(MS =VENSATION LAWS OF Ftp APPUCANT'S SIGNATURE TITLE -Contractor _.PA 1215/03 01APPROVED PLAN REVIFEWW3 5V -SD WITH CONDITION(S) CI MM COMMONS BELOW AWM ON ATTACMeM DA"Z"E� 04 ANY omoms mom Tmis AppucAnoN musr sE suommwro am r-oR AppRovAL PA- " TO comeNcNo wo CONDMONS: ................... 0&