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From Ivan Ve9vary & Associates PHONE No. : 510 947 1051 9.08 1997 8:17AM PO4 <br /> -a/ <br /> SAN J0A(2M COUNTY PUBLIC HEALTH SERVICES <br /> ENyMoNMEPJTAT. HEALTH DIVISION <br /> APPLICATION FUR UNDERGROUND STORAGE TANK CLOSURE PIMMIT <br /> TaMCE <br /> EXPIRESNN DAAYYSPFROM TTHE/APPROVALYDATE. DOONOTNWRITEMINT ANY SHADED AREAS. GROLAID NDICATEAPERMITGT7YPESSTORAGE TANK <br /> CLOSURE IN PLArL OF BELOW: <br /> AL _ _ ORARY CLOSVRC ,CLOSURE IN PLACE <br /> EPA SITE N PROJECT C TACT i TELEPHONE N <br /> IACILITY NAME I�UN//�/✓CiL7 r/ O/l�if/NY PNp1E N •Jyj•J.�f'� . <br /> L CRoq STACEY <br /> T OWNER/OPERATOR PHONE N <br /> Y �oj� 11 <br /> C CONTRACTOR NAME b),t/^/ ? �j A40 PHONE <br /> N CONTRACTOR ADDRESS � / `�Y 4V4W(le- -.S&, CA lIC N N� CLAss <br /> z <br /> R INSURER <br /> A PERMIT • <br /> C FIRE DISTRICT S"3L ��Np/ry✓//VP COUNTY(,-./ -• � .��.r7o <br /> 0 LABORATORY MME I T <br /> R Ya <br /> SAMPLING FIRM /✓� �FL4Np�Y. �s-rar._. PxoNE N�ryv•yy�-/�.S' <br /> 111111111111111111111111 11111 <br /> J_p <br /> TAN N TSTRMR <br /> IZ CNE (CAIS SED BINRRlMTtY/P0.EYIWSIY DATE UIST STALLED <br /> 39•TAZs� nANK c�r,4l/ay S7 <br /> �Ts' <br /> i 39- <br /> A 39- <br /> N 39• <br /> K 39- <br /> 39-- <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN Ntv WRNc"'� NAME DATE _ <br /> I I I I I I I I I I I I 1111111 I I I I I I I I I l l i i l I I I I I I I I I I I I I I I I I I I I I I 111111111111111111111111111111111111111111111111111111111111111 1111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND RtVULATIONS Of <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1-1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CUNTRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 111 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 9t CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �lar �7 7� TITLEDATE G� <br /> CONDITION(S): <br /> IN 23 046 (Rev(ARd 7/70/96) PRp! 3 <br />