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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE P£RMTT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZAR000S SUBSTANCE STORAGE TANK <br /> EXPIRES 90 VATS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS_ INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE 0 CAO J�93 o-I S PROJECT CONTACT L TELEPHONE WT <br /> JJ GAR- r✓�I 1-`6�b•a1i- SSi <br /> A FACILITY NAME "'L (7LAT OI.� L FJ PRONE r Q'�p '-'')��j_ Iylt'K o <br /> I ADDRESS P7J5� kAs50Q ROAD I�L 1'53 /(O <br /> I <br /> L CROSS STREET 1/V_ .W 1 C <br /> 1 5 <br /> T OWNER/OPERATOR <br /> WIL(Ax /J,DEPT/. CI (Akctrcrlo,�S PHONE Rami $3s yryic,> ya o <br /> C CONTRACTOR NAME `5. 14rJ M-W L PHONE A - S3S y <br /> M CONTRACTOR ADDRESS 517 GFI _ CA LIC B /_I3 O CLASS�_ NAZ <br /> T --..___ 5 - 13 (�lu.Sag1,C__C12. J] (O C <br /> A INSURER Sr�-� mP. n�V/RAWJce ]-VETO WORK.COMP.R I'IVv7�3 -5J7 <br /> T FIRE DISTRICT � JQjQV,� "FJN RAe JIrq OLd9VOAA PERMIT ofip-7vaaoy FP--S <br /> R11LABORATORY 11N1A1M1E1S111111111111/11 'TYr COUNTY 9500tN C,I/S)/.S � PHONE r -3( <br /> - 4 <br /> /7 <br /> SAMPLING FIRM 9//D <br /> VlnK` ` L PHONE p <br /> `Il b- /3/-53 <br /> TANK 10 N 2c, TANK SIZE CHEMICALS STORED CURRENTLT/PREVIDALT OAT UST INSTALLED <br /> A 39- <br /> N 39- O #i <br /> - —_]LLC. <br /> K 39- —— <br /> 39- <br /> 39- <br /> P 1111 I 11 1111 IIIIIIIII IIIIIIIIIII I IIIIIIIIIII <br /> L APPRO APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CDMVITIONS BELOW AND/OR ON ATTACHMENT) <br /> " �� 3 <br /> PLAN REVIEWER'S NAME /UL DATE <br /> nunnunnlnnnnnllnlllrllllll111n111111i11111111111111111111111nnunnuunuuununuunnnnununm <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAWIM COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS of <br /> SAN JOAQUIN COUNTY PUBLIC WEALTH 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 HUMMER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNI ' CONTRA 'S NIRiNG OR SUBCONTRACi1pe SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE O THE WORK F WHICH TBI PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE- -- TITLE 11e471ECi14;1* DATE <br /> CONDMONN: <br /> 3a ) �j(Dcoo� dry �c� - 0 Ivt�- <br /> EN 23 046 (Reviser] 9/11/96) cAyo <br />