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R6CF� lvi <br />ENVIRONMENTAL HEALTH DIVISION I�/ Ju Eli <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PA/o' ,,M �O 9 )J`VL1 <br />ANK <br />APPLICATION <br />PE RM[TFOR <br />E%PERESN90TDAYSP PROMYTHECLOSURE <br />APPROVALABANDONMENT <br />NON WRITE CE OIN ANYERGROUNDSHADED INDfSCA'1ijkc TPT LOW: <br />';,_ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />*TnU1cS TO PL50 $k 1-%-ff2c> fa¢ Lf4b*g GAS'7LINf <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE #ap' %) 5 <br />PI '2 <br />PROJECT CONTACT & TELEPHONE # 410cc ID I LL A, L510 • b <br />F <br />FACILITY NAME 5 WELL SiGU111-IE S-fcr-)l <br />PHONE # -z c)9 - Lrn <br />A <br />C <br />ADDRESS 3O 1) I� Sp <br />a2�J £O L TD <br />1 <br />L <br />CROSS STREET <br />(J O Yr: M <br />JP1 <br />T <br />OWNER/OPERATOR <br />PHONES # <br />Y <br />SNS <br />1L <br />/ / W <br />5)D ^ (p% ^ 45 <br />C <br />CONTRACTOR NAME K IE <br />T vJ-gA e.,-N)Oo <br />PHONE #sib - 7 -9 511 <br />0 <br />N <br />CONTRACTOR ADDRESS 2.1 y s j .DVtt LCO,� <br />CA LIC # i-9 � -� p p <br />CLASS 1\ Z L. & 1�A 2 Z <br />T <br />R <br />INSURER 6-�OLDYa <br />WORK -COMP -0 pi <br />L <br />u N N cv <br />WW c-3z3z <br />A <br />C <br />FIRE DISTRICT CI D F <br />To o f <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME S�G2,�DIh <br />m b F, C- 1 <br />Z L PHONE #E)/b' -1' 0o <br />R <br />SAMPLING FIRM f <br />TANK ID # <br />p <br />PHONE # - CJ S�ZJ <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />lo3t)c l: <br />r nC r.]��Ij K(R•N LAS ti.�1-f+�in <br />1.�.11LUo... w+ <br />A <br />39-ots <br />�. <br />t_...r L�sS Pe�am ��.. �. '•.., 1101 <br />..uu-�l nom✓ <br />N <br />39- <br />. c r <br />r-..cr Ltas the �pnsn �w� <br />n k.wt C ws <br />K <br />39- <br />39- <br />39- <br />P <br />L <br />_ <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />(SEE ATTAC MENT WITH CONDITIONS) <br />DATE Z S �'( <br />N <br />PLAN REVIEWERS NAME t <br />1111111111[11111111[ <br />�- <br />APPLICANT MUST PERFORM ALL WORK <br />IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR <br />WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION <br />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 CALIFORNIA." <br />APPLICANT'S SIGNATURE: :%i+i+rt'/�yt/ <br />L/C3--- �G� TITLE i>P41RY DATE '7- <br />*TnU1cS TO PL50 $k 1-%-ff2c> fa¢ Lf4b*g GAS'7LINf <br />EH 23 046 (Revised 4/26/94) Page 3 <br />