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W11212092 23:19 2894583433 FIFTH FLOOR <br /> SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> AppLiCATHtIN FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> TMS AGE T FOR <br /> CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE ANK($)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT <br /> &1MtOVAL TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> —rt, TiU� - - i1�tsTr� �o rL�srw�►��.f a� ?r�oPSL '� <br /> rADRESS <br /> ..... ,.:::. . :. . . " 't`�=6ITE# JEC7 CONTACT D �U �� ON O9 O1ILLTY NAMEv -ne tD's eraONE# <br /> NER OPERATOR <br /> :Ct ..RACT(,.,I.1FDRMATION ': . • : .' ' . . .. <br /> CONTRA NAME ,... t nIV3P4IJ - / V PHONE# V O <br /> coNTRAcroRpDDaEss ba R!I ( PD cAlat# AI+2T1cSw <br /> INSURER /'X (r ^ 1� -r mCi > I WORKERCOMPS C-) <br /> FIRE DISTRICT PERMIT# <br /> L ABORA'&Y NAME PHONE# <br /> SAMPLING FIRM l 4 PHONEY L T4 G <br /> TANK INF_QRMATION':. <br /> TANK ID# TANKSIZE TANK CONTENTS &. P DATE.INSTALLED <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUkTY ORDWAN%CES.STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTII'93 THE <br /> FOLLOWING -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON N SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSAY" LAM OF CALIFORNIA.' CGSIRACTOWS HIR4".0 OR SU15CONTRAGTNG <br /> SIGNATURE CERTIFIES THE FOLLOWING: T CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL EMPLOY <br /> PLRSON9SUBJECT TO.WORKERS COW S OF CALIFORNIA' <br /> AFRLICA $IP.NATU _ TITL.E �� DATE &fjo— <br /> PTI- <br /> tl <br /> ❑,APPROVED HCONDITION(S)Ai'PI20VEDWIT -PI 'DISA* ROVED; <br /> ..(SEE FiBf-DW MIDRIB OKAZTAOFB�NTT . <br /> PLAN REVIEWER'$NAME <br /> ANYDEVIPeT#0JSFR[IMT1}k4APFUCAIIONvUST BH SU811H1?6tt1'QEND FORAPPROYAL PRIOR•70C k.. <br /> : . • N 1. ONS. <. _4 <br /> AAJ <br /> CH 23 M(REVISED 31ISM2) Page 3 <br />