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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT iN PLACE.OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE I ANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICA TE PERMIT TYPE_ <br /> l9 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> ' FACILITY INFORMATION <br /> EPASITE.(-NATO 002iIb8 I PROJECT CONTACT 5C_67- ' TA+-WaPiLL I PHONE-, 7O7- 7&5-)(a(ov <br /> FACILITY NAMEAL°.1 FII= b(f" PHONE <br /> ADDRESS 771 SoLI FI ELM -S-1. tib- 'CIS �M SiOC(tTO� CA• <br /> CROSS STREET ELM ST. (1eDvll40c E' PHONE _ 75 7-GS7S <br /> OWNEROPERATOR A 1 FI r6ELI— <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME ! /` PHONE T 5B•aG90 <br /> CONTRACTOR ADDRESS !/ CA UC x CLASS�"'7�• & <br /> NSURER <br /> — - WORKER COMP: — <br /> FIRE DISTRICT I PERMfT,. <br /> LABORATORY NAME /VI P6EL-L1 ��1- T-I A"L- COUNTY PHONE <br /> SAMP!ING FIRM — AOR "-L01� I PHONE -' <br /> TANK INFORMATION <br /> TANK 10 m TANK SIZE TANK CONTENTS(PRESENT 3 FAST) DATE INSTALLED <br /> 39- l�l 6C o0o GaL . L71E s--_c_ SS <br /> 31- <br /> 39- <br /> 39- <br /> 139- <br /> 139- <br /> APPLICANT <br /> 9- <br /> 39- <br /> 39- <br /> 3 39- <br /> 1 39- I 4 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN CCUNTY OROINANC'-S. STATE LAWS. FEDERAL LAWS.ANC RULES ANO <br /> REGUUTIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGoNTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMP!OY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNAI.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE=CLLCW WG: 'I CERTIFY THAT IN THE PERFORMANCE OF t HE'NORK FOR WHICH THIS PE`MIT IS ISSUE").I SHALL EMPLOY PERSONS-SUBJECT TO <br /> 'NCRKE.RS COMPNSATION LAWS OF CAUFORNIA." <br /> APPLICANTS SIGNATURE„ � ,17-'—" i;'a^ <br /> `f <br /> ❑ APPROVED APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> Sc CON4-1,03ELCMW ANOICR ON Ai�ACHh1EPIT) f�,`yA <br /> OA=- <br /> ' ?IAV REVIEWERSNAME <br /> ' ANY DEVIATIONS FROM THIS APPLICATION -MUST BE SUBMTED TO EHO FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> n n ONDITI S: <br /> ' I <br />