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111%" 0141ENTAL HEALTH <br /> �T <br /> SF VICE <br /> ENVIRONMENTAL HEALTH DIVISION 93 OCT -6 PM 2: 11 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> IMENT IN PLACE ND <br /> STORAG <br /> TANK <br /> APPLICATION <br /> FOR PIREBN90TDAYSPORROMY7 CLOSURE THE APPROOORR ADANDW DO NOT WRITE OIN ANY E SHAD D AREAS . INDICATEBELOW:PERMIT TYPE BELOW: <br /> X REMOVAL __ TEMPORARY CLOSURE CLOSURE 1N PLACE <br /> PROJECT CONTACT d TELEPHONE IV Suzanne Felice (916) 368-0988 <br /> EPA SITE # CAC 001 017 816 PHONE f <br /> (209) 948-5569 <br /> F FACILITY NAME KJAX Radio Transmitter <br /> A <br /> C ADDRESS Harding Way <br /> Ier Lane <br /> L CROSS STREET 1/4-mile west of Bey PHONE 0 <br /> 1 (202) 646-3061 <br /> T OWNER/OPERATOR FED7A acting on behalf of FCC <br /> Y <br /> PHONE k (209) 524-965 <br /> C CONTRACTOR NAME SEP•ICO CLASS $r C61/D40 <br /> 0 o 449864 <br /> N CONTRACTOR ADDRESS 1217 SO. 7th St• r Mode s CA U LIC u r <br /> T WORK.COMP.M <br /> R INSURER AYWEST Surety <br /> A PERMIT 0 <br /> C FIRE DISTRICT Waterloo - Morada Fire Prevention Bureau <br /> T PHONE 0 (415) 364-9600 <br /> O LABORATORY NAME Sg uoia Analytical <br /> RHONE <br /> SAMPLING FIRM Woodward-Clyde Federal Servic / (916) 368-098 <br /> I IIIIIIIIITI^KII pi I�IIIIIIIIIII [HEMI LS ST ED CUR ENTLY/PREVIOUSLY DATE <br /> UST INSTALLjD <br /> 39 as, �_ID N/A �aprox- <br /> 7 <br /> TAiKV6b gallon c iese fue� 17b 39- <br /> 7 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> i fffffTmffffffw <br /> iiimmmmTmTnTrffamffumTffmmmTMOT'MffmffmffffmffmTmTmuuff <br /> P DISAPPROVED <br /> L APPROVED PPROV X H CONDITIONS / I <br /> A q�Tb, WITH CONOI TIONS) DATE <br /> N PLAN REVIEWERS NAME ' �/ rYTYrr7YYTT7TTTT �IIIII <br /> IIIIIIIIIIIIIIIIIIII �I�111tt �������� <br /> 1111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 70 BECOME <br /> SUBJECTCERTIFY WORKER'S <br /> INSTHE PERFORMANCEAWS OF OF TTHECAWORKOFORAWHICHOTHISCPERMITN ISNG OR ISSUED,SUBCONTRACTING <br /> EMPLOYGNATURE PERSONS SUBJECTSS THE 10 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.-IA, / ` �� <br /> l�F� .Y./ � 7.1// �� ls��w//( 711LE /C�� r�L� �rG DAIS <br /> APPLICANT'S SIGN'RTURE: �!>�—� <br /> EH 23 046 (Revised 7/10/92) Paye 3 <br />