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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAY 2 7 2003 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PIERM, <br /> ,_.:.,FF,pp;��qqI II77MJJ(QEN�ppT��H� EALTH <br /> THIS PERMIT FOR PERMANENTI TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUP$Sl71tlST'AYV'CES ICES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE; <br /> B"TAREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE'IN PLACE <br /> FACILITY INFORMATION <br /> EPASITE#CALOOOIDSI963 PROJECTCONTACT UC. 'MI IPHONE# c1Z5' 3SS— 2—ez <br /> FACILITY NAME 7- (e.�e^ 5+o e Z 7- - 3Zz c<Z PHONE# ZU G 30- <br /> ADDRESS Z31po LA) Cvr 1,-� -R a T✓ac, G 453 6 <br /> CROSSSTREET -'o H_ 13ory o `-Pkw <br /> OWNEROPERATOR -1- E .n Zno. PHONE# Log yZ4- 8 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME GrIac ei h ,r �c I kr✓taLs I PHONE# <br /> CONTRACTOR ADDRESS {-/L/�(O i�v5s.•,ll Rac.�t, 5-,+ CA LIC# '7 A-13 (3 CLASS <br /> INSURER G -:: ��., -� a. Iv vL Z. WORKER COMP-, ((e 4 .p <br /> FIRE DISTRICT C,V O ru. PERMIT# p <br /> LABORATORY NAME KIPS' Arkl Ica COUNTY D PHONE# 530 Z4 <br /> SAMPLING FIRM �ti ¢ _ IPHONE # ) <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT 8 PAST DATE INSTALLED <br /> 39- 1 Is Ooo GaS, I,ti, 3'ul 144 <br /> 39- z o ,o Ga <br /> [39- <br /> 9- o 0 0 o u I <br /> ( 999 <br /> 9- <br /> 9- <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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A6 <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA' _ <br /> APPLICANTS SIGNATURE lX� TITLE �BS l �I, 7- <br /> / <br /> DATE � 03 <br /> FREVIEWETR-S <br /> ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> DATE <br /> OM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 1 EH 23 046(REVISED 06113199) Page 3 <br /> i <br />