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SAN JOAQU-L7 COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNIE,`+TAL HEALTH DMSION <br /> APPLICATION FOR LNDERGROL,'�D STORAGE TANK CLOSURE PEIL4IlT <br /> THE PERMIT FOR PERMANE4T/TEEXPCRARY CLOSURE OR AEANDCNMENT IN PLACE OF UNDERGRCLUNO HAZARDWS SUSSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FRGn THE APPROVAL DATE. DO NOT WRITE I4 ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPCRARY CLOSURE CLOSURE 14 PLACE Qf <br /> iEPA SITE [�II / �^�j3 7„6d j PROJECT CZMTACT 3 TELEPHCNE '+ (. [QA.I� �I' � Y67-100 j <br /> IPHONE I <br /> CGCF'Lbc/4 (� —�! <br /> F i FACILITY NAME - I <br /> A � !^ , _ CA— 25203 <br /> C DF S <br /> L j CROSS STREET c744,•-G i Q <br /> PY.C4E '.I C:NER/CPERAi OR � �2�l3� 'n <br /> Cj CCNTRACTCR .4An"e <br /> ,EvyQIcP� ai+�e<a�m ��— I PHONE 2a� yG7 16(Db I <br /> O 1X/1. i j C;. LTG G8p'�7 I C'-n'S!162 f <br /> 4 1=N R CTOR CDRESS 1/105 �/JSol I ✓�r'KT// 1, <br /> '7 <br /> R INSURER <br /> A II ,PERMIT <br /> CFIRE 'ISTRICT S-}�C,YL-�Lo� T 7�'FoQ � <br /> OR i LASCRATCRY NAME YECt5c�, "t4-Y T i PHCNE <br /> i <br /> EAnPL!NG Flan )✓iG En�rW� GME `r�2—Og�Z <br /> I I 11111111!11111 <br /> ' AKK :D TANK 512E 1 CH :II <br /> ECALS STCRE9 GRRENTLY/PREY ICUS�. I .AT_ <br /> : .11111111111111 UST .45TAL-_7 <br /> '$• I i 1 d J u <br /> A <br /> 4 <br /> C 39- <br /> -.9- <br /> P <br /> 9-%y-P DISAPPROVED <br /> L APPROVED APPRCVED '41TH CCNDIi ICN(S) <br /> A ( E- CCNOI7;CNS BELOW ANO/CR CH ATTACHi4ENT) — <br /> N - <br /> ?LAN RE`/?E':ERAN <br /> 'S ME - ` DATE <br /> 111111111111111111111111111111111111111111111111111111 1111111111IIIIIIIfill 11IIIIllIII11111fill 11111111111111111fill 1111111 <br /> AP?Li CANT MUST PERFORM ALL ':CRK !N ACCCFCA4CE WITH SAN 'CACUIN COUNTY ORDINANCES, STATE LAW'S, AND RULES AND RE=UATIC4S OF <br /> SAN :CACUI.4 COUNTY PVSLIC :1EALTH SERVICES. CWNER OR LICENSE-) AGENT'S SIGNATURE CERT:. THE FOLLL41NG4 NE3•AS_TC1=ECCME7 IN <br /> THE PERFCFMANCE OF THE WORK FCR 'WHICH THIS PERMIT IS ISS::ED, ! SHALL NCT EMPLOY ANY PERSON IN UCH A . <br /> SUa^^:ECT TO 'W'ORKER'S CGMPENSAT?C4 LAWS OF UL?FORN!A." C'NTRACTCRIS Hi.R1NG OR SLECCNTRACT!NG Si GNA iCa`_ CEaTi F:ES THE FCLLC'W 1NG: <br /> SU CEaTI FY "HAT 1N THE PERFCRMAHCE OF THE WJCRK FCR VH!CN THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SLSJE-- TO WORKER'S <br /> CCMPENSATICN LAWS OF CALIFORNIA." <br /> AFPL:CAHT'S SIGNATURE: <br /> WWKQ TITLE \'CLr'9� O^�� DATE 7rs'/ <br /> C ONDITION(S): <br /> p ,A p p r o vie �o •2.Le. d �( I a J �®x �d <br /> PaSe <br /> EH 2S G-6 (Revised 7/10/96) i <br />