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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FAPPROVAL E. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAD 9g 2_030 iq-73 PROJECT CONTACT & TELEPHONE # A15 [-NGINEEPING Bra' ?42-3"4, <br /> F FACILITY NAME OCAc0N tL + 1 �f PHONE # 209 Q"L$ X34 + <br /> A h <br /> C ADDRESS f-70 MAIN ST. M AN'rf cA <br /> I <br /> L CROSS STREET A -A iv 6:DA <br /> I <br /> Y OWNER/OPERATOR ULTR AMAX (IVC PHONE SS3 32 275 <br /> C CONTRACTOR NAME J(V J CONST-(ZVCTIDr/ PHONE #Zo 2.j9 1746 <br /> 0 / <br /> N CONTRACTOR ADDRESSq'�o E• SHAW caov15 936(f CA LIC # pgZ74Z CLASS A g Nqz <br /> T WORK.COMP.# CL P 5 <br /> R INSURER SLATE FUND <br /> A <br /> C FIRE DISTRICT PERMIT <br /> T <br /> 0 LABORATORY NAME K)FF ANAUtTIcAL COUNTY DAMS C�} PHONE a �j(� 297 q-goo <br /> R EL Do <br /> SAMPLING FIRM RRDo E/v\iReNMENTAL PHONE # 916 L263898 <br /> NK <br /> IIIIIIIIIIIIIIIIIIIIIIillil <br /> NK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY TE UST INSTALLED <br /> 39- l )11 Gq -"t45 (5 50 t- NE 4N'a'7d'Y'f' <br /> T 39- -QZ• 10000 GhL- <br /> A 39- 1 qqt- 0.2I OOOOCR�- <br /> N 39- <br /> K 39- <br /> 39- <br /> 139- <br /> IIIIIIIIIIIIIIIIIIIIIIIII1111111�1111111111111111111111111111111111111111111111111111111111111 <br /> P / <br /> L A APPROVED ✓ APPROVED WITH CONDITION(S) DISAPPROVED <br /> � A �(S�T[ONS BELOW ANO/OR ON ATTACHMENT)[ONS BELOW ANO/OR ON ATTACHMENT) <br /> N DATE Z ( V <br /> PLAN REVIEWER'S NAME <br /> 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 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 CALIFORNIA." q <br /> APPLICANT'S SIGNATURE: �gTITL/E P(zos• C-GR . DATE x'.24. 9 <br /> CONDITION(S): 1) !(I�l f�(� r) ,a 'IV1�iUK/� �R � ) TPN o1 T3f-x/ 10 }d Pb . 94f <br /> offcj W, P)ff) rro) fRrY1E 44-(ir 6J01A ea6ogt,o E iia// tin <br /> EH 23 046 (Revise 9/11/96) all # 4/ Page 3 <br />