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I <br />ENVIRONMENTAL HEALTH DIVISION <br />r <br />RECEIVED <br />MAR 121996 <br />ENVIRONMEN IAL HEALTH <br />PERMIT / SERVICES <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />LA 6.1atG A"CAtc4e) '7f/Le, tdwk wvs Mas+ 'Ikcl/' R G63.01/4c :/( / <br />GoAIQ!?'iv�S= /,Pjj /G��EGIv¢'fts,6,�T-S f.R. S�derd� T� �±tAIG /5 3oi6s�oW� <br />EH 23 046 (Revised 7/10/92) Pape 3 <br />EPA SITE # QfAt Oo%Z0'► S(oo <br />PROJECT CONTACT i TELEPHONE # -zo�LN I.YN-,q QZOR) $aa—WISB <br />F <br />A <br />FACILITY NAME `%\NG <br />PHONE / 10 rlA%-33Toy <br />C <br />I <br />ADDRESS 21331.( \FJ, STgTE �DUTE 1-4 STOGKTpN1 CA gSZO� <br />L <br />I <br />CROSS STREET UNC. N OW N <br />T <br />Y <br />OWNER/OPERATOR <br />I� �-C\NG TY1v5T <br />PHONE If <br />(5I0)'198-336`1 <br />C <br />0 <br />CONTRACTOR NAME W0.\6H\ FNV\\20NMeNM1. SVCS LNC. <br />-PHONE 0 (LOq,lb33-o'lSb <br />N <br />CONTRACTOR ADDRESS y220 Mw\cRC\Q\ .1 STe - S <br />CA LIC / (�S( $o <br />A . <br />CLASS HAZ <br />T <br />q 7 <br />R <br />A <br />INSURER ��TPT£ V4N1p <br />WORK.COMP.# 13126ti5 <br />C <br />T <br />(\ [^ <br />FIRE DISTRICT CJ��', �OVU i\'RE £VfNT�o �� f <br />PERMIT # Fp Ct(e p�\'3 <br />0 <br />R <br />LABORATORY MANE 2R\oa\�y £NwtiaNM(nl"CPI. 1.(aa5 mllP\sqs �A <br />PHONE #(LA 08)ci%♦(o-963(0 <br />1 <br />SAMPLING FIRM \ti \'Z Ty F-Av\Z.'�NME'JTW, 1�T�3s (\\1�-(�1 CA PHONE #(AO$) CALA(o <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />5b0 qo- <br />'a.l V, No, <br />L)NdNCWN <br />A <br />39- <br />v <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P IIII <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />_ <br />A SEE ATTACHMEMT WITH CONDITIONS) <br />N PLAN <br />REVIEWERS NAME DATE <br />I I I11111111111111111 I I I I I <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: 1-1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 1S ISSUED, I SMALL 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 CALIF(A." <br />4A &NkC �) <br />APPLICANT'S SIGNATURE: k TITLE / DATE <br />r I e i4 c,, -,f <br />LA 6.1atG A"CAtc4e) '7f/Le, tdwk wvs Mas+ 'Ikcl/' R G63.01/4c :/( / <br />GoAIQ!?'iv�S= /,Pjj /G��EGIv¢'fts,6,�T-S f.R. S�derd� T� �±tAIG /5 3oi6s�oW� <br />EH 23 046 (Revised 7/10/92) Pape 3 <br />