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r ,/20/2006 12:49 2094640138 ENVIRONMENTAL HF^I.TH PAGE 03/11 <br /> ENVIRONMENTAL,HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT F PE RMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STO K XPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> MOVAL ❑ TEMPORARY CLOSURE 0 CLOSURE IN PLACE <br /> EPA SITE• 1 ROJECT CONTACT / - I� <br /> FACILITY NAM PHONE# Ql <br /> ADDRESS Z<741 fl1LI S. Cq. <br /> CROSSSTREET (ZI <br /> OWNER OPERATORS Me-� 7a+ Se�A,�s�+ E� y,��L."J PHONE# <br /> 'bO T%Wti,Fi I, R'I4Y, ,Rl7c�' IV-. . :. <br /> CONTRACTOR NAME <br /> CONTRACTOR ADDRESS hl, CLASSG/ol <br /> INSURER WORKER COMP# <br /> FIRE DISTRIC PERMIT# <br /> LABORATORY NAME MCOUNTY PHONE# 'LS 2S'L - <br /> SAMPLING FIRM PHONE# <br /> T. rt Ir�:FoxrA� <br /> rag:> <br /> TANK ID# TANK SIZE I T NK CONTENTS PRESENT& PAST DATE INSTALLED <br /> goo C" <br /> 3g <br /> 39� <br /> 39= <br /> 3� <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'$ SIGNATURE CERTIFIES THE <br /> FOLLOWING: T CERTIFY THAT IN THE PER RMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO SEGO OBJECT 7 WORKER'S COMPENSATION LAWS OF CALIFORNIA' CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIfIES T %FOLLq --RRTTJJEEyyTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I$$UED, I $HALL <br /> EMPLOY PERSONS SUBJECO ER' DMPENSATIORUI F CALIFORNIA' <br /> APPLICANT'S SIGNATURTITLE frt ,L� t V'-+P64A-- DATfi/7--?,F'-d'6 <br /> D /iPPaOVEDAPPRZOVED7. lf1TH- ON ITIO . (S) ODI APPROV€D <br /> '(SEE ITN M04,ATTACHMEA4 .. AA-7 <br /> PLAN-RE.VIEWERS'NWWME � �( Z DATE/ &Z/ ./ <br /> ANY DEVYATKJNS"KRbM TK13'APPLICkTR)N MUST U.SUSFAITTED TO EHD FOR APPROVAL PRIOR TO.COMMMENCINCs WORK. <br /> CONCITIO'NS: <br /> S.z,c, r.et:K <br /> 6H 23 046 (Rcviscd 11/21/06) 3 <br />