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PF). Box 388,SI0d(tOn,CA 95201-0388 <br /> Phone: (209)468-3420 <br /> >%k-VP,: <br /> k;.P,: •'Md►'mkh ch2fV"' See Remarks <br /> 1304a; rrvved: See Remarks <br /> P.emarkz; _ _ <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> M'?LI CATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ��((''{{QQQQpp (p���n(�ee f <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT 1N PLACE OF UN�AASOUSS[165�fA$CF�SA�T . Q only to thG <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN AN A&EAS mmA)Q WP.1C& :he, tK <br /> does not authorize or approve any vrnissio <br /> REMOVAL _ TEMPORARY CLOSURE - 110 -Jh uirements <br /> @ <br /> EPA SITE # CAT 0& Z�/� PROJECT CONTACT i TELEPHONE lyPAPFNw <br /> VF BLS LLlctA <br /> F FACILITY NAME 11/ O 1 PHONE # <br /> A iii L <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y PcG - 5t - �23.3 ' <br /> ` 0 c <br /> I C CONTRACTOR NAMEI ` ,,1L PHONE <br /> ,^ # <br /> 1 0 <br /> N CONTRACTOR ADDRESSLQ ,� �t, CA LIC # S9ZoLo CLASS L-Io <br /> T <br /> �{ A INSURER GoLurN r'W"'e (tl WORK.COMP.# hLuG <br /> C FIRE DISTRICT w&•. t�l �.. I PERMIT # Fp_ 946 Q 2 <br /> T <br /> 0 LABORATORY NAME /-�U PHONE # 5L Q, •Z• l� <br /> R �l <br /> iiSAMPLING tiFiItRtM , 0 -, PHONE CIO , 37-z - qU <br /> cc <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY CAT= UST !NSTALLED <br /> Y39- <br /> T d <br /> ltntLf� 4pA� $dL LntE LII <br /> 39- /F . 000 - h,— l <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> TL _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A - (S E ATTa�HMENT TH CONDITIONS) r� <br /> N PLAN REVIEWERS NAME •L..�- cSl'1] C9 DATE 3- t <br /> IIIIIIIII11111111111 111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGJLATIONS 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 1N 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 YORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE/I✓ O KJ�7/iIJrLZ-JfF'A�S TITLE fA�TiE�4-Ctit�S!/L)% TE �, <br /> onc(cfT�"s ; � c.sol Ke io K 4-at,k <br /> r �L c sa_)J k �TaJtik SO`LQ s,DN��c a -(a o r <br /> -` 23 046 (Revised 4/26/94) Page 3 <br />