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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH D"ION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> O( REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # bill e�(JGrS+Gr ffp5to) L{1(p-558-7roI4 <br /> F FACILITY NAME 6irGIG K raGllity 301205 PHONE # <br /> A <br /> C ADDRESS 169470 6am6riqJ C ariVG , L-.r 1hr0 <br /> L CROSS STREET Louise, Ar•G <br /> T OWNER/OPERATORPHONE # <br /> Y -f,%o NarkeFing Company (91&) 556-7Cn12 <br /> C CONTRACTOR NAME 2k4l Ple roleurn PHONE # 406) -142.- Wt& <br /> 0 <br /> N CONTRACTOR ADDRESS 930 Ames Ave . Milpitas CA LIC # 311(p157r:> I CLASS <br /> T p <br /> R INSURER Ko Uielia lrndewinl Go. 4 Amerie2 WORK.COMP.# 97P655111G2 <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T �_y� <br /> 0 LABORATORY NAME p017 AMI +iL9l (.'ilsS COUNTY �OS CO, I PHONE # 510 g68j ,q((6 <br /> R <br /> SAMPLING FIRM KgPrealtmn Enginccrin' �on�,pra1 („A PHONE # (510� &b2 <br /> T <br /> IIIIIIIIIIIIIIIIIIIIIIIII <br /> TANNKK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 1I I I I I I I I I I I IIIII IIII I I I I I I IIIII I I I I I I I I I I I I I I I I 11111 I I I III!I I I I Ifii�fi-7I I I I I I11I I I <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( E CONOII��TIONS BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAME - l• w��� DATE l <br /> —111111111111111111111111 11111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN 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 WHICH THIS PERMIT IS ISSUED, 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." 1 <br /> APPLICANT'S SIGNATURE: Cof RNL DYJJ h (�rou inG TITLE �CYr 4�lf TO'SLD DATE G 23 9- - <br /> 1'IIGf' C.O. <br /> CONDITION(S): < - <br /> E4 23 046 (Revised 9/11/96) Page 3 <br />