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uo <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL BEAT TH3 DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERNIIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> t EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED ARW. INDICATE PERMIT TYPE BELOW: <br />{I REMOVAL TF-iPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITECAL PROJECT pNTAG7 b TELEPHONE 9 l <br /> F FACILITY NAME A4 -AY-1- PHONE a ;LOI-13 I -0%60 <br /> C <br />� 1 ADDRESS 3133 W. A Ar•#' Raad 5TocK16 <br /> L CROSS STREET C h yb K t t e a <br /> I <br /> T OWNER/OPERATOR ,} _ ~� t/ y PHONE I / <br /> Y M� A✓ I v q�l l FockQ'f be-r5pr j ;coq-q? I - ojDo <br /> d <br /> C CONTRACTOR NAME ed PHONE * �oj • q6 -t-1006 <br /> a �9� v'avlc ,o kmvlrommoi ct � <br /> 0 " <br /> N CONTRACTOR ADDRESS 4005' X/. Wt If011 Wcty CA3 LIC 1 610 ;-2-7 CLASS <br /> R INSURER A Cord — pAqI#N 9w0oh -,- r) -mcitq. � WORK.CDMP.� 1317Li <br /> A <br /> C FIRE DISTRICT Wctl-Ar loo / MoraActI PERMIT 4 <br /> T " - <br /> k 0 LABORATORY NAME A �4g A K4 1 '1 1 Cot. I C7UNTY Ma tdO C i K O k PHONE 0 -1o7 - 4b$ -0 d l <br /> R ,y <br /> SAMPLING FIRM A Imc, A Na ly l Cq I I ! PHONE 4 70 7 • q6g -OqO I <br /> lllllllllll[ttlltlli[[Illlllll — <br /> TANKD ; TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY . DATE UST INSTALLED <br /> 39- � - 0,-: EJC! rte .. 7 F r 1 - <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 11111111lIllllllfilllllll! 11 11111 II llllilli !ltlllllllli I 1ll1ll!! 1111111!llllliillllllllllll�lilll lllllllllillll <br /> P <br /> L APPROVED 2K APPROVED WITH CONDITION(5) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/CR'ON ATTACHMENT) <br /> N f <br /> PLAN REVIEWER'S NAME (_ � G�• '�/ i -< .� �; _ DATE <br /> [fill 1111111111111 <br /> 14 APPLICANT MUST PERFORM ALL WORK 19 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />[ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHIfiH THIS PERMIT 3S 155iJED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 3t <br /> APPLICANT'S SIGNATURE: XK-1 TITLE ,sf• s�q' U 'OtOgqI S1 DATE <br /> _ 1 — <br /> 1 <br /> CON-D_moDl(S3' _�..._.�..-----__.—__...._..-___._._..-_...— _ �—_____ — _ � __ -• -- �_ <br /> Y� .1_.____��_--��_-._. <br /> EM 23 046 (Revised!!/73/96) r jti L, Page 3 <br /> C7✓ tl 'L ( L L. I L L n 11 t L( v^v1 '' r /� �; 11 �±(f�� <br />