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05/10/99 09:18 FAX 425 251 8782 BARGHAUSEN Z003 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION :FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />TI -115 PERMIT OR PGAMANENTITEMPORARY CLOSURE OR ABANDONMENT W PLACE OF UNDERGROUND HAZARDOUS SU65TANCES <br />STORAGE T K(S) EXI-kES 9C DAYS FROM THE APPROVAL, DATE DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE <br />I <br />AR�MOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />! <br />FACILITY INFORMATION <br />EPA Sri's a <br />PROJECT CONTACT N ! lej� PH( <br />FACILITY E <br />AooRt^ss I -- <br />'Li0 �/YI P Fi�G PhfOPIE p� ?t�j _ <br />/{c E. -?; �v C, k14Y f c -4--K <br />CROSS 15TRE�ET <br />GEiv%L'YZ -'57,-o <br />OWNER;CP TOR <br />GA L� / / CZ D PHONE >i 7 ln�0 ' t" <br />I <br />TANK0 0 i TANK SIZE <br />TANK INFORMATION <br />TANK CONTENTS (PRESENT & PAS'(} DATE INSTAL! ED <br />CONTRACTOR INFORMATION <br />CONTRACTO <br />CONTRALTO <br />NOME .: , F erV --!Z <br />ADDRESS 7 S r <br />1z,14 -Al „v c , PHON>~ x 9 z f- 5'S/- 794 <br />u r r CALIC Nt Z26793 CLAS5 A$ <br />wsusER m,4rscw <br />0&wegs WORKERCOMPM WidQcy�pB>'�ic�/ <br />FIRE DISTRIC <br />j / /=P <br />LABORAITOR <br />NAME ! <S' `. [/U/ <br />Yr/ COUNTY PHONE r. <br />SAJNPLI, G Fl <br />PHONE Nt <br />I <br />TANK0 0 i TANK SIZE <br />TANK INFORMATION <br />TANK CONTENTS (PRESENT & PAS'(} DATE INSTAL! ED <br />39- ! /2090 <br />'72 <br />39- ; Z ; . /Z- <br />-7 ! iL <br />39- 022 <br />39- I <br />39- <br />APPLICAMT MUgT PERFQRM ALL. WORK IN ACCORDANCE VATH SAN JOAQUIN COUNTY ORDR4AlCES, STATE LAM FEDERAL LAWS, AND RULES ANO <br />REGULATIONS EBF SAN *)O%QVW COUNTY PUMX HEALTH SERV'NCES. OWNER OR Lr2KSM AGENTS =MATURE CERTIFIES THE FOLLOVO NG: 7 <br />CERTIFY IN THE 13WORMANGE OF M4E WORK FQR WHIGI yM PERW IS I$SUM, 1 SHN 1, oiOT OAPLOY ANY PERso1V W SUCH A M/Wi�FR AS <br />Es�SPEENSAT"44 <br />TO *KWJMFCS COMPENSATION LAWS OF CALiFORN1A,* CONTRACTOR'S MRUNR OR SUBCONTRACTING SIGNATURE CERnneS <br />iHAY� TME WORK FOR %WC}4 TN7S PF�NY IS [SS m. 1 S:14L £MPI,QY 'PERSONS SUBJECT TO <br />L.l LlfAHWrI• / <br />APPLICANT'S �IGNATlIF2$�'!��/Y 'SLE,�/l�t'}2C��lTffi l C DA 4 % <br />L7 APPROVED ❑APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />I (SEE CONCiOXM BELOW ANDnFz ON ATTACH ENT) <br />PIAN RE: AVL NmF- <br />OA'iE <br />ANY DF'YIATION5 FROM THIS APPLICATION, WJST BE SUBMITTED TO Effl) FOR APPROVAL PRIOR TO C:QlAMa4CING WORK. <br />CONDITIONS: <br />Pulte 3 <br />