INSTALL 2007 PARTIAL TANK TOP UPGRADE & EVR

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RECEIVED ENVIRONMENTAL HEALTH DEPARTMElYA12 3 2007 SAN JOAQUIN COUNTY ENVIPoaMENTHEWH APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PffANVII" THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAG TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE a FACILITY INFORMATION EPA SITE # PROJECT CONTACT ✓ O� PHONE# -711f- 5-60 - k O cD FACILITY NAME .4 C o AM / P vvl PHONE # ADDRESS 130 W1LTQ( ,(c 0 -u Co1 RSZ 5 - CROSS STREET r OWNER OPERATOR JEST (,D tb r (La Duc,-t uc PHONE # 7/ - 5-60 - b Soo a APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDfvi REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNLN FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT A MANNER AS TO BECOME SUBJECT TOWORKER'S COMPENSATION LAWS OF CALIFORI SIGNATURE CERTIFIES THE FOLLOWING: .,I CERTIFY THAT IN THE PERFORMANCE OF THE EMPLOY PERSONS SUBJECT TO WORKER'S COM ENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE TITLE CES, STATE LAWS, FEDERAL LAWS, AND RULES AND OR LICENSED AGENT'S SIGNATURE CERTIFIES THE ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH �CONTRACTOR'S HIRING OR SUBCONTRACTING QRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL C --A T ❑ APPROVED ❑ APPROVED WITH CONDITION(S) (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL CONDITIONS: EH 23 046 (Revised 8/9/06) TE 01 -Z,? -0-7 ❑ DISAPPROVED 1901110 CONTRACTOR INFORMATION TANK ID # CONTRACTOR NAME T41r vl O✓1 w%e-" 3 rEw)S FPHONE# '7/6- &5-6-101C) CONTRACTOR ADDRESS 1 ('Z. '�S O - 4 z) CW CA LIC # 5-cd4rDq `6 CLASS r42 : C -!0 INSURER MLAmlvrLc4,5 C u / Sv✓u WORKER COMP# OA -c ao 3 o5-3,7,' 9706 FIRE DISTRICT .¢ PERMIT # X12 - 3SG -J LABORATORY NAME C-SY COUNTY ��4C , PHONE # JDLto" CC SAMPLING FIRM EC PHONE # 5-10 _ - 03:r- / APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDfvi REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNLN FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT A MANNER AS TO BECOME SUBJECT TOWORKER'S COMPENSATION LAWS OF CALIFORI SIGNATURE CERTIFIES THE FOLLOWING: .,I CERTIFY THAT IN THE PERFORMANCE OF THE EMPLOY PERSONS SUBJECT TO WORKER'S COM ENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE TITLE CES, STATE LAWS, FEDERAL LAWS, AND RULES AND OR LICENSED AGENT'S SIGNATURE CERTIFIES THE ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH �CONTRACTOR'S HIRING OR SUBCONTRACTING QRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL C --A T ❑ APPROVED ❑ APPROVED WITH CONDITION(S) (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL CONDITIONS: EH 23 046 (Revised 8/9/06) TE 01 -Z,? -0-7 ❑ DISAPPROVED 1901110 TAN INFORMATION TANK ID # TANK SIZE TAN ONTENTS PRESENT & PAST DATE INSTALLED 39- �? oo �, �f �,> w 39- 12 0 op u CE ., 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDfvi REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNLN FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT A MANNER AS TO BECOME SUBJECT TOWORKER'S COMPENSATION LAWS OF CALIFORI SIGNATURE CERTIFIES THE FOLLOWING: .,I CERTIFY THAT IN THE PERFORMANCE OF THE EMPLOY PERSONS SUBJECT TO WORKER'S COM ENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE TITLE CES, STATE LAWS, FEDERAL LAWS, AND RULES AND OR LICENSED AGENT'S SIGNATURE CERTIFIES THE ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH �CONTRACTOR'S HIRING OR SUBCONTRACTING QRK FOR WHICH THIS PERMIT IS ISSUED, I SHALL C --A T ❑ APPROVED ❑ APPROVED WITH CONDITION(S) (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL CONDITIONS: EH 23 046 (Revised 8/9/06) TE 01 -Z,? -0-7 ❑ DISAPPROVED 1901110