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Post -It- brand tax transmittal memo 7 <br /># of pages . <br />To S0 <br />n/�AS.ca, <br />From 49 <br />Co. ";47— ✓. <br />Ce. s. SDept. <br />Phone Phone # n <br />L16�'o3s <br />Fax # <br />Fax # <br />RECEl` QED <br />MAR 121996 <br />ENVIRONMEt' iAL HEALTH <br />PERMIT / SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND RSUBSTANCE STORAGE TANK <br />AREAS' INDICATE <br />CATE p`RMIT TYPE BELOW: <br />THIS PERMIT EXPIRES g0 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADEDACLOSURE IN PLACE <br />�i REMOVAL _ TEMPORARY CLOSURE <br />/ioq� F333 —6'1 S�3 <br />EPA S)TE #CAC OO z 09 S Co O PROJECT CONTACT S TELEPHONE f 3p\.AA I,nI NCFf <br />PHONE 0 sto '1`L8-33�y <br />FACILITY NAME L-y7N Zi <br />or'a <br />ADDRESS 33 Lk <br />CROSS STREET UNY-^1 ow hl PHONE <br />T OWNER/OPERATOR <br />T I�gOM E SC\IJG Tc V� \ <br />SVCS Ln)C. -PHONE # <LCq> 63�u -Cr158 <br />CONTRACTOR NAME L.AiQ\GHQ Ef`�V`�'>;�.fJM— N/}Z <br />0 4220 MY+� qC�P� 'JK•I ATL' a CA LIC F CLASS A <br />N CONTRACTOR ADDRESS _;L WORK. COMPS t -3126y Gt <br />T <br />R INSURER CjTPTE fl _ PERMIT # t=-*? C�61Z)CA ` <br />AE�CwT.oN �" 2C <br />C FIRE DISTRICT CJ J • CCjv u \!ZE C• PHONE $ �\oti� Ca'ib-9b3� <br />T <br />0 LABORATORY NAME�i7�p.Z�t�1 ENV`�c•LCt.I \A� Fr'iC5 m'1 -F \TFiS P PHONE >Y (L•1�8� ���:0 —��3{' <br />R <br />SAMPLING FIRM\0\Z\T� �N\TL�Eh(i-Fil.�I <br />IIIIIIIIIIIIIIIIIIIIIIIIIIIIII TANK SIZE CHEMICALS STORE CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANK ID: i....i,.o uu,nl <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- wwwww <br />39- <br />IIII APPROVED ,( DISAPPROVED / <br />�i P E APPROV <br />,L, E WITH CONDITION(S) <br />L SEE ATTACHMENT WITH CONDITIONS) DATE <br />II N PLAN REVIEWERS NAME IIIII <br />IIIIIIIIIIIIIIIIIIII AND RULES AND REGULATIONS OF <br />APPLICANT MUST PERFORM ALL YORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS. <br />SAN <br />APPLICANT <br />M COUNTY PUBLIC HEALTH SERVICES- OWNER OR LICENSE AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE YORK FOR VSERV THIS PERMIT IS 155A1ED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SIBJECT TO CERTIFYY THAT INSTHHEE rPERFORMANCE OF THE WORIK�FORAWHICHH THISCPERMITH IS ISSUED,NG OR �B�ALLLLCEMPLOYTING I PERSONS SUBJECTCERTIFIES <br />TOTHE <br />WORKERLSWING: <br />COMPENSATION LAWS OF CALIF IA.' <br />TITLE W n �6 L '� DATE �I <br />APPLICANT'S SIGNATURE: ° re 51 6/L• <br />Lw�iCn�r,J -7'hc '�G{14+-ie� L(Jw /NGS'{- �HC11 A Go Srl/�+Lc /G.•.K a <br />I.G`7 ✓��i`[w�L1` AA Ck4.. V F �U51[.Gi, w{. � C[ �/.i /I01/� 2t�V� . <br />jZc G tTaLht V / t Tl� n1� /s 3� bs/:soo <br />'�- C-c,Jn; ;rv�.IS� P21 rC��: ta�:�.`i`+�c,�rs f�2 ;,,,rte`•, � � <br />Page 3 <br />ER Z3 046 (Revised 7/10/92) <br />