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10(17/2000 09:00 2094683433 FIFTH FLOOR PAGE 03 <br /> SAN JOAQUIN COUNTY PUBLIC KLALTH SERVICES <br /> j� ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERVtANENTITEMPORAFZY CLOSURE OR ABANDONMLN;IN PLACE OF UNDERGROUND -L+ZARDOUS SU38TANCES <br /> STORAGE TANYyS)E�6'IRES 90 DAYO#PEON THE APPROVAL DATE, OO NDT WRITE IN ANY SHADED AREAU. INDICATE PERMITTYPE; <br /> ! REMOVAL ❑ TEMPORARY CLOSURE —'CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> @PA SIT PR ECT CC94TACT PHONES 09G no� <br /> -Eylmft—"� PACIFTC AVE. ARCO <br /> AZORE$6 PN NE x <br /> CROSS S77= _ <br /> OWNER OPERAT'0RYr7vTA <br /> PFION <br /> CONTRACTOR INFORMATION <br /> TRACTOR NA1AE <br /> PHORiE• - _ _ <br /> coxrRAc7naaooaFss 694 cA ucF <br /> INSURERC��DllrrqINRICER OIu1Pik <br /> KIRE DI PFRMIT# <br /> LAaORATORYNAMEMCCAMPRFI I ANAI R'41 CQVNTYCQUlpaPHONE# _ <br /> SAMPLING FIRMfNr�—IYT <br /> PHONE Y <br /> TANK INFORMATION <br /> TANK 10 N TAN SIZE I TAN CONTENTS RESENTS PPS DATE INSTALLED <br /> 39- <br /> 39- 10.000 <br /> 39- 10,0 0 GA�ni INF <br /> 39- <br /> 39- <br /> 39- <br /> APPLZANT VUST PERFORM ALL WORK IN ACCOIWANCE WITH SAN JOAQUIN COUNTY ORDwANCE$,STATE LAWS,FFOFRAL LAWS,ANC RULES ANf) <br /> REGLi ATION$ OF SAN JOAOUNa COUNTY PUBLIC WALTM SERVICEE. OWNER(Kt UQ9"ED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: <br /> CERiTFY THAT IN THE PQR/ORµ4NOE OF THE WORK FOR WMICFi Tl$§PERMIT J ISSUgp,1 SMALL NOT EMPLOY ANY PER$OIJ IN$t,ldi A b1A1iNER AS <br /> TO F O LO ING:ZLUBICY TO rY TMAT B e pq- SATION c O OF GALJIYWNIA.' DONTPACTOR'S HIWNG OR SL*WONTTtACTNG SIGNATURE CERTWi <br /> THE FOLLOWING: I C IUTON TW7 Iry TAE FCf4,%FiMANCE OF"F WORK FOR W KICM TM16 PIRN17'IS iWP5,1$HALL EMPLOY►ERA N1S SU9JECT TO <br /> Wf7�R'9 CCAIRENSATIOII Ww,OK ULLITCRTM' <br /> APPUCANT$SIGNATURE TITLE 0IIIj tIATE <br /> 0 APPROVED ED-APPROVED WITH CONDITION(S) D DISAPPROVED <br /> (SEE CONDITIONS 9ELUW ANLYOR ON ATTACHMQ M <br /> PLAN REVIEWER$NAM �w��cv_/ OATS <br /> ANY 0IEVIATION6 FROM T1115 APPLIOATKM MUST BE SUBMTTT@D TO FhV FOR APPROVAL PRtSjktT0 COPY <br /> CONDITIONS: <br /> EH 29 Od6(REVISED 06'191DI) Pago 3 <br /> uln )NI 9IVUD v M ZZ69 C69 LOL TFd 99:9T 00/C9/0T <br />