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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 /> x REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # E �( 2�S,�� PROJECT CONTACT & TELEPHONE # ({qi �i, q-q,� �3 <br /> F FACILITY NAME eA% VIP-0 PHONE <br /> A I /�AUS �7 <br /> C ADDRESS I boo ' 7614 <br /> t <br /> LCROSS STREET .� <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y AA"&C&- UK <br /> 1 <br /> -zoq) sw- <br /> C CONTRACTOR NAME Sala) PHONE # (209) 524-9653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. t-'todesto, CA 95351 CA LIC # 449864 CLASS A,B,C61/D40 <br /> T <br /> R INSURER Calcomp Insurance Company uoRK.COMP.# W964137662 <br /> A <br /> C FIRE DISTRICT 4A& -t PERMIT # <br /> T IV` <br /> 0 LABORATORY NAME Geoanalytical Tab COUNTY Stanislaus PHONE # (209) 572-0900 <br /> R <br /> SAMPLING FIRM Geoanalytical Lab PHONE # (209) 572-0900 <br /> IIIIIIIIII HIM IIIIIIIIIII III <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY D6E UST INSTALLED <br /> 39- C7 (v'%t.lLUt.� la(L� i LeLt�x+ <br /> T 39- /060 C+ Pu LIQ LZ44R. <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> L APPROVED V! APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW ANO/OR ON ATTACHMENT) <br /> N ,.�T`�`/�\ <br /> PLAN REVIEWER'S NAM \( ftL .. DATE H <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 PERFOR CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL[FORN A." <br /> APPLICANT'S SIGNATURE: L TITLE DATE 7 L'q 7 <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. n_ <br /> 'J MP quo. g i S �lJ��, %4- t a``OLA C Eal �. G Rfa p-- <br /> C`gS0`iNE � <br /> cz+`a vr � tlm� se. �P t c as <br /> ply t ���r <br /> EH 23 046 (Revised 7/10/96) ege 3 <br />