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SAN JC*UIN COUNTY PUBLIC HEALTH *VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AI:P{+ORATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TA"j/E7f PTgq%DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> �F �;MQVALc( ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> -�- ,H SERIACE <br /> Ed`SVIFOhJ1�1t�r,,gL HEALTH OIVISi <br /> FACILITY INFORMATION <br /> EPASITE# CAD11820301-13 1 PROJECTCONTACT AAS ENGtNEERIP PHONE# 818823`¢ <br /> FACILITY NAME gE <br /> c o N it 2 PHONE# <br /> ADDRESS A70 MAIN ST. M ANTEC IN <br /> CROSS STREET ALA NL6 D A <br /> OWNER OPERATOR LTR A m AR INC • PHONE# 209 rj$3 3235 <br /> CONTRACTOR INFORMATION <br /> CONTRACTORNAME )NS Co /vSTRUcTtoV PHONE# 20929917 46 <br /> CONTRACTOR ADDRESSI2-0O E. SHAW C )_ oV1S 36(l CA LIC# (i 2- 1Q•2- I CLASS A R NAz <br /> INSURER TATE uJS WORKER COMP# CC P 5221110 <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME KiFF ANAL-YT tc AL- COUNTY 0 VlS CA PHONE# �6 2°x"1 Soo <br /> SAMPLING FIRM 5 EN V(ILO IJ ME^/TAI- PHONE # 91b G26 3$ 8 <br /> TANK INFORMATION <br /> TANK 10# I TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- 0000 GAL- G ASoLtNE J/vr-. <br /> 39 0000 GAL- GA IOL INE vNh• <br /> 39- 10000 GAL. (�AS0L-( N6 VN K. <br /> 39- 375 GAL- u V. � <br /> 39- <br /> 39- <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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 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 TITLE <br /> PRD. EGK. DATE 1l-lo-9g <br /> FREVIEWER'S <br /> PPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> AME DATE <br /> FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: 6 <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />