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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION . � '� 1,J <br /> &&4 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CL� ,4kRW1: 43 <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> 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 a,,r <br /> EPA SITE # e,41- DOO D©,S 7 PROJECT CONTACT & TELEPHONE # -fe gXt( � L D Vu SM-qW,; <br /> F FACILITY NAME COWP1 E- k -r(9,C PHONE # Obq) g45,(v)0b <br /> A ff''F1__ Tp� <br /> C ADDRESS U51 {'C �-tf L/t <br /> I <br /> L CROSS STREET 2 <br /> Y OWNER/OPERATOR 4AA R �" l PHONE #(4(007- 760,5I& <br /> 4(S`0 7- 760,5 <br /> C CONTRACTOR NAME , Lel PHONE # (209) 524-91653 <br /> 0 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. Modesto, CA 95351 CA LID # 449864 CLASS A,B,C61/D40 <br /> T <br /> R INSURER Calcomp Insurance Company WORK.COMP.#W964137662 <br /> A / <br /> C FIRE DISTRICT (�( 0,C PERMIT # <br /> T //-� <br /> 0 LABORATORY NAME �19X�fE S-rA rE CNDI,QDA1 COUNTY PHONE #(y1S), 58$-L4TiK <br /> R <br /> SAMPLING FIRM }fG• PRONE #(y IS <br /> Sr7L$D 3; <br /> Illilll111111lllllllillllilfll <br /> TANK 10 # T�1 IK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- $rj0 (7,fL(,6�.J J.1745TC U11 '� <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> illl I I I I I I i t I 11111 I IIIIIIIII111111111111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITION BELOW AND/OR ON ATTACHMENT) <br /> " �8 PLAN REVIEWER'S NAME L- DATE t2 <br /> ilia 111111 IIIIIIIII111111111111111111111111111111111111111111111111111111111111111111111 <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: 9 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR YHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATIGN 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 CAL <br /> APPLICANT'S SIGNATURE: ✓ "" ""�''Z. TITLE AjetdC 1'"l7! QYJ aef DATE 11-tK 10 <br /> CONDITION(S): Underground Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> EH 23 046 (Revised 7/10/96) Page 3 <br />