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2-0a-1�--399 d:a%PH FPCiM P. d <br /> SAN JUAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTTE.MPORARY CLOSURE OR ASANDCNMEN T IN PLACE OF UNDERGROUND HAZARDOUS SU6STANCES <br /> STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE, <br /> Mr--i "�' L L� TEMPORARY CLQ$URE Cl CLOSURE IN PLACE <br /> I"C�iVIV Vh1L <br /> FACILITY INFORMATION <br /> EPA SITE# I PROJECTCONTACT C>e\ PHONE# -;Locl— qlc, Z1>7, <br /> FACILITY NAME A&D �# c� <br /> I PHONE# t� <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR PHONE# -7 kci (01O SM <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 4> o Tv C Q I PHONE# <br /> CONTRACTOR ADDRESS �� �1 1)p� �� CALIC 9�iS QQ) CLASS Int YqF;v.�, <br /> INSURER yY� / I WORKER COMP# UjC O!� }x-15 S <br /> FIRE DISTRICT S�COG j PERMITS <br /> LABORATORY NAME �}�k ( �� COUNTY p l PHONE# ?S3 d <br /> SAMFUNG FIRM I PHONE a "i <br /> TANK INFORNIAT <br /> TANK 10# TANK SIZE TANK CCN T cN (PRES PAS-) I DATE INSTALLED <br /> 39- l L)F- `b <br /> 39- 'p- I �� <br /> 39- <br /> 39- <br /> 139- I <br /> APP!ICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN.OAQUIN COUNTY ORDINANCES. STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. CV1'NER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$ <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALFORNLA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERT IFtE$ <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERF CE OF THE WORK=OR WHICH THIS PERANT I$ISSUED,I SHALL F2APLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LA OF LI NIA." / <br /> APPLICANT'S SIGNATURE TiTL= _ f(1r_TI1 CCt 1"'tnLc1LV OATS S/ <br /> I Q APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CCNDITICNS BELOW AND/OR ON ATTACHMENT) <br /> I I I <br /> PLAN REVIEWER'SNAME 1 % / I. DATE <br /> . i <br /> ANY DEVIATIONS FROM THIS APPUCATION MUST SE'SU' MITTED 70 EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITI NS:(7 F97y- <br /> M <br /> I _ <br /> 77) <br /> 7,77 <br /> �- <br /> L.�1 ZX <br /> /- <br /> EM 23 Q f{REVISED 1011 81 page 3 ' <br />