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SAN ,]#,,QU1N COUNTY PUBLIC HEALTHWRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE: PERMIT <br /> NCES <br /> STTPERMIT FOR PERMANEN0 DAYS FROMY CEO PPREOVAL DATE. O NOTBANDONMENT iN PLACE W'RI E IN.ANY SHADE❑CUND AREAS. INDICDOUS ATE AT•E PERMITATYPE- <br /> STORAGE TANK(S)EXPIRES 9d DAYS FROM TH <br /> i� REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> PHONE# 707- 7&57-166oD <br /> EPA SITE# T D dC7 I o8 PROJECT CONTACT SCOTT TA +�� L LL PHONE <br /> FACILITY NAME ASL FI Cr br=_L-L- <br /> ADDRESS -7-7 I 5-0114 <br /> cRcass sTRL;r G�--M �- +' o°� <br /> PHCNE# & 757-6575 <br /> OWNER OPERATOR A IFI �L - <br /> CONTRACTOR INFORMATION <br /> PHONE# C57?11k 5� <br /> CONTRACTOR NAME A LIC# �9 CLASS YA <br /> CONTRACTOR ADDRESS �&u Z4220�� <br /> WORKER COMP# <br /> INSURER <br /> PERMIT'- <br /> FIRE <br /> ERMIT# _ <br /> FIRE DISTRICT — �` _ O PHONE# Z5- Q <br /> LABORATORY NAME M A P�3�►-J � �— r� �-- coUNrr I[ <br /> SAMPLING FIRM �p(j --mid PHONE M <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE 1 . <br /> TANK CONTENTS{PRESENT& PAST} DATE INSTALL=❑ <br /> 39- c 000 ClA4L-• �I� �.�� <br /> 39- <br /> 39- <br /> 39- <br /> 39- ., <br /> 39- <br /> aILAWS, NC <br /> APPUCANT MUST FCQ � AOACLI OG' <br /> OWNER RSED AGcTS SIGNATURE CRTFiESHLN <br /> REGULATIONS OF SANOAQUIN COUNTY PUBLIC HEALTH S IC <br /> I SHALL � OI <br /> CERTIFY THAT N THE PERFORMANCE OFPi$OFORHS PERMIT <br /> IISL <br /> TO BECOME SUBJECT TO WORKERSMRNLAWS ©FCALIFORNIA.- AG�OR S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING. '1 CERTIFY THAT IN THE PERFORMANCE OF THE'NORK FOR°NHiC;-I THIS.PERMIT IS 15SUE6,I SHALL EMPI,QY PERSONS SUBJECT T <br /> WCRKER'S CCMPENSATICN LAWS OF CALIFCRNiA.' <br /> GATEI TL <br /> �}L <br /> APPLICANTS SIGNATURE f <br /> •i <br /> APPROVED PPRROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> Ell (SE,CONDITIONS 3ELOW PNCICR CN ATTACHMENT) <br /> LATE <br /> i PLAN REVIENCR°S NAW <br /> ANY DEVIATIONS FROM TI-IIS APPLICAT10N MUST SE SUND TIONSHD FOR APPROVAL PRfIOR_10—C-0 MlMENCING WORK. <br /> r <br /> 9I <br /> k <br /> A <br /> I <br /> EH 23 048 (REVISED 3811 3i99) Page 3 <br />