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1� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES OCT ,9 p 1998 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PETITFN <br /> . <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCEBRABRALTrMWv�alU <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: N <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE '�IN PLACE <br /> Y,52 - 2,9/0 <br /> EPA SITE # C(Y�' (�� `/'vJ J L11.,7 0 PROJECT CONTACT & TELEPHONE # N,J�,�YU L ,tog <br /> F FACILITY NAME AJ1,4 PRONE # /�.'1A <br /> Ci <br /> A <br /> C ADDRESS 7-5-0o Gf <br /> I <br /> L CROSS STREET C ($HAAJ <br /> I may/ <br /> T OWNER/OPERATOR tka (U1VVA(ZA J /L PHONE # `.� ( e vv� <br /> Y beg//JJ/� ,1 J F7 7-9 <br /> � p <br /> C CONTRACTOR NAME D IE/ L / ('-k/GA-� PHONE # ,205 .P3 Z — - /U <br /> N CONTRACTOR ADDRESS F6 / CilttVl Y (� 2 CA LIC # Gj 3�ZO CLASS A - AA z, <br /> R INSURER GLIL(e- `-1 <br /> —(Ai5-V We-Z �C' � �/'� lWORK.COMP.# <br /> C FIRE DISTRICT (r, ( /�!-*L� PERMIT # �J,/ B G <br /> 0 BORATORY NAME C�14A LA 19 COUNTY /-�LA'MEdA PHONE # �Z� ,7 "r- / <br /> SAMPLING FIRM - 1• - u �. fJ PHONE # <br /> AXIAZ <br /> !K 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39-�/Z OI 00(u �� U 0 ,0 <br /> T 39 'L 0 IF It 11 12r.� <br /> A 39- <br /> N 39- <br /> K 39- N r U.1ir dA <br /> 39- <br /> 39- 1 HIIIIIIIIIII <br /> P <br /> L PPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A E C N ITIONS BELOW AND/OR ON ATTACHMENT) � <br /> N PLAN REVIEWER'S NAME DATE pl/T(�J/ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS 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 15 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE �C /49:� <br /> CONDITION(S): <br /> 1) <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />