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SAN JOAQULY COUNTY PLBLIC HEALTH SERVICES <br /> ENVIRO.,,'NM'N'T.t,L HEALTH DIVISION' <br /> APPLICATION FOR Uti"DERGROUND STORAGE TA`'K CLOSURE PEEL'1f[T <br /> THE PERMIT FOR PERMANENT/TEMPCRARY CLOSURE OR ASANCCNM-ENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> E%P(RES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHAD. AREAS. INDICATE PERMIT !TPE SEELCJ: <br /> REMOVAL TEMPORARY CLOSURE C'_CSJRE 14 PLACE <br /> =Ea SITE L G)o( 153 26D I PRo:Ecr caNTAc; a TELEPHONE ; /4q <br /> F I FACMTY NAME GcI PHONE <br /> A <br /> ADDRESS 'Eft�,o SOwTYI �C Dc)¢.9 i1 D s?) t Sl1 C4- X520 3 <br /> ' CROSS STREET <!4t�,c h <br /> I <br /> i C'.MEER/CPERATOR / PHONE <br /> Y * 1_4,aS fJG�w�r <br /> C C^N-RA -CeNA <br /> PHCNE 20'� k7-1606 <br /> 0 ^ <br /> N /✓2YL / SC ) <br /> (�(/ CA L!C A GgpZZ�-7 I C'.a55/1_ d <br /> 7 INSURER <br /> J ' I L'CRK.CCNP.� PIPIT <br /> C -;RE DISTMC- S-!UC/U ?ERHIi <br /> 0 , LABORATORY 4'uI OCU4i'( I PHCNE <br /> .RI ^ rl E�tSt�A 7fGF4 ' n TDvWa� <br /> SAMPLING _;RM Zptit� Ef / �(rW� I PscNE a2—p�72 <br /> I I I I(11111 <br /> TANK 711111111111111 <br /> ' <br /> TANK IO = TANK SIZE STORED GRRE4i LY/PRE'/iCUSLY I DATE US. !NSTALLEO <br /> T 79- <br /> I Ea- I <br /> A 39- <br /> N 39- — (n' I i • �� — Je i I� <br /> K 39 <br /> 39- <br /> Illllllllllllllillllillllllill IIIIIII11111111111111111111111111111111111111111111illllllllllllll I1111f111111111111111111111 <br /> � P �/' <br /> L <br /> APPROVED / APPECVEO WITHCCNOITION(S) DISAPPROVED <br /> p (SE�-�CC40[i:CRS 5-LCV ANO/CR ON Ai;AC:iAE4T) <br /> N - /�- 9 <br /> ?LAN R /I=:ER'S NAME DATE <br /> Illlllllllllllilllllllllillllllllllll1111111111 IIIlillllllllliiilllllllilllllllllilillllillllllllllllllllll11111111111111111I <br /> APPLICANT ML'S; PERF'CRM ALL 'JCRK 14 ACCCROANCE WITH SAN :CACUIN C LINTY CRO(NANCES, STATE LAWS, ANO RULES AND RE7';LATiCNS CF <br /> SAN :CACUIN CC' PUBLIC HEALTH SERVICES. OWNER CR L!CE95EJ AGENT'S SIGNATURE CERTIFIES THE FOLLCWING: "! CERTIFY THAT iV <br /> ;HE PERFORMANCE OF THE WORK FOR WHICR THIS PERMIT (S I53CEJ, ! SHALL NOT EMPLGY ANY PERSON IN SUCH A MANNER AS TO 3EECC4E <br /> SUe:ECT TO WCRKER'S COMPENSATION LAWS OF CAL!FCRNIA." C-NTRACTCR'S 4?R!.4G CR SUEC"NTRACT!NG SIG.L'ATCRE CERTi F(EE THE FOLLCW14G: <br /> "! CERTIFY THAT IN THE PERFORMANQ OF THE WCRK FOR VHIC4-THIS PERMIT IS ISSUED, I SHALL EMPLOY ?ERSG.YS SL'EJECT TC ':CRKER'S <br /> CCMPENSATICN LAWS OF CALIFORNIA.., <br /> - <br /> APP'-:CANTS SIGNATURE: - """ fiT TITLE \-C9R`�'"TVK DATE <br /> C ON'DMON(S) <br /> 'Srr erg u/•D, Tsvrr,(�L �.r. /�/� , c >?- 1 pDa� "wzG <br /> �ti <br /> E:4 23 C-6 (Revised 7/10/96) ?age 3 <br />