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SAN <br /> J O A fl� � �41 Environmental Health Department <br /> +J►ICOUNTYE 4� I 1 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE E PERMIT <br /> THIS PERMIT FOR PE#tMANENTITEMPORARY CLp5URE OR ABANDGHMENT IN PLACE OF UNDERGROLIND IIAZARI ous <br /> SUBSTANCES STOPAGI=TAW(S)EXPIRFS lea OAYS fROM THE APPRWA4 RATE, DO NOT VvRITE IN ANY SHAI]EU AREAS_ <br /> iNDtCAXTE PERMIT TYPE: <br /> ❑ REMOVAL IN TEMPORARY CLOSURE U CLOSURE IN PLACE <br /> ':FAG ILITY INFORMATION <br /> EPASITE# PROJECT CONTACT Kimberly Harris PHONEt1 <br /> FACILITY NAME San Joaquin County Sheriffs Opera#ion$Nl F3HONEa a 119..d�8.45�15 <br /> ADME5S 7000 N Michael CaT�J[s Blvd French Camp 95231 <br /> CROSS STREET <br /> OMr;R OPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME Bagley Enterprises, Inc PHONC i# 209.367.4800 <br /> CONTRACTOR ADDRESS 2370 M file Clr#4 LDdk 95240 CA LIC# 774802 CLASS A <br /> INSURER Insurance of e West 1 WORKER ODMIRN WSD507145901 <br /> 1=IRC DIVRICT Weg PERmrr# <br /> LABORATORY NAME A COUNTY PHONE <br /> SAMPLINGFIRM NA PHONE it <br /> TANK INFORMATION <br /> TANK lb# TANK SIZE TANK CONTENTS WRESENT AND PAS DATE WSTALLED <br /> 39- 10181419-002 60106 gallon., diesel 4'k�11I989 <br /> 9- <br /> 39- <br /> 9- <br /> 39- <br /> APPLICANT MUSY PERFORM ALL V"K IN ACCORI)MCE VOITH SAN JOAOUIN COUNTY OW)IMMCES•STATE LAY&.FEDERAL LAWS,AND RULES WWI] <br /> REGULATIONS OF SAN JOAQtAW C4U47V ENVIROMMENTAt f1EALTH MPARTMEHT. OWNER OR LICSVISED AGENT'S SIGNATURE CERWII:S THE <br /> FQt LOWING; 'I OER71FY THAT IN THE PERFORM010E OF THE WORK FOR WHICH THIS PF RE UT LS ISSUED,I SHALL 140T PLOY ANY PERSON IN SUCH <br /> A MANNER AS TO UECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFOltNW CONTRACTOR'S HIRING OR SUUCONIWTIN13 <br /> SIat4ATURE CERTIFIES THE FOLLOW I`#G- 'I CERTIFY THAT 1N 71-1E PERFORMA ICE OF THE WORK FOR VOMICH THIS PERMIT IS 13SUE1}, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WOR1ER'S 0 WPENSATION tAVYS OF CAUFORHIA.' <br /> APPLI.CANTSSAcNATURE �� �• Tt7L� Admen DA7EV2412025 <br /> I <br /> ❑ APPROVES XAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> �y+ AMP <br /> PLAN REVIEV4rEI 'S NAME !'weer P Fnnch Camp-MoXinley FIm DIsiTIrA-stalesnopenilf tided DATE "LZ—!5 <br /> ANY DEVIATIGNS FROM THIS APPLICATION MUST 9E SUBMITTED TO EH FOR APPROVAL PRIOR TO Comm ENCINn WORK. <br /> CONDITIONS: <br /> 3 nI 10 <br />