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SAN JOAQUIN COUNTY PUBLIC HEALTH MRVICES <br /> ENVIRONME gTAL HEALTH DIVISION <br /> APPLICATION FOR UNDF RGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERKANENTlTEMPURARY CLOSURE,OR ABANDONMENT IN PUCE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM 114E APPROVAL DATE, 00 NOT URIYE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PI-ACE <br /> EPA SITE a 2152tPROJECT CONTACT l TELEPHONE a <br /> F FACILITY NAME NONE a <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T MMER/OPERATOR PHONE a 331-7�,� <br /> Y �� <br /> I -�' '.�' <br /> CCONTRACTOR NAME w\ '� PHONE a � _ <br /> 0 5 <br /> N CONTRACTOR AWRESS a O �'^'"^^QCC-`Q- 'oo,- Tv's- C0. LIC a IS CLASS <br /> T WRK.COMP.O <br /> 0. INSURER ; £q [}6 <br /> A { PERMIT a 3 D <br /> C fiAE DISTRICT <br /> I <br /> 0 LABORATORY NAME CQ1N7Y PHONE a ur _ <br /> R <br /> SAMPLING F[RM szoylpll �1. (..Q-�4Oc[�tp'I`i'P '�I Try[s. ' PHONE aye, ,. <br /> TANK t I II7i,,,Iu <br /> TIQ a TANK SIZE CHE.NIULS STOIREQ CURB NTLY/PREYIOU5LY DATE UST INSTALLED <br /> 39• _ t (O O A/rw Anw <br /> T 39• is 6 <br /> A 39- - �• <br /> x 39• o <br /> K 39- <br /> 39• <br /> 1111 Iimmuffmff7fi7 <br /> P <br /> L APPROVED _Y APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AIO/OR ON ATTACHMENT) <br /> N tG r F 4, Z7 9 <br /> PLAN REVIEWER'S NAME OATS <br /> IIIHIII IIII If IIIIII11III111111 IMIIIIIIIIIIIIIIIIIIIIIIIIIIII1111111111111111111111111111111111111111111111111111IH111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AMD R)1LES AN R=Rjj TIONS OF <br /> SAN JOAQUIN COUNTY PUSLSC HEALTH SERVICES. OWNER OR LI4°NSLD AGENT'S SIONATLOE CERTIFIES THE FOLLOWING; •11 CSRTI F7 THAT IM <br /> THE PERFORMANCE OF THE UORK FOR WHICH TNI3 PERMIT IS ISSUED, I SNALC NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO YORKER'S COMPENSATION LAUB OF CALIFC9HIA." roNTRACTIM-s MINING OM SUBCUTRACYING SICNATUPE CERTIFIES THE POLLODUIG!, <br /> ^1 CERTIFY THAT IN THE PERFORMANCE OF TOE YORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF GLIFOWI ^ <br /> APPLICANT'S SIGNATURE: A TITLE DATE —ZF� <br /> A <br /> CONDCMON(S): <br /> EN 23 066 (Ravi See 9117/94) ►SHB 3 <br /> ZO 3E)Vcd 35UlN3WNOdIAN3 1H9I21M ZSIGZ6860ZT ST=91 L66I/01/ZL <br />