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10/17/2000' 09:00 20946836g3 FIFTH FLOOR _ PAGE 03 <br /> DI <br /> SAN JVAQUIN COUNTY PUBLIC HEALTH SERVIC ����I`-�� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSUFW 9F"#00 <br /> THIS PERMIT FOR PERMANENMTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROU4H S'SU®87 ui$ <br /> STORAGE TANVIS)EXPIRES 9D DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. I � <br /> HPF: <br /> U REMOVAL ❑ TEMPORARY CLOSURE X(p CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PRRIECT CONTACT Y�KTAPHONE# <br /> FACILITY NAME PHDNE# <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATORyPI(TAPHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME PHONE# <br /> CONTRACT 6940 TR CA ucz LA s <br /> INSURER WORKER OMR# <br /> PIREDISTRICT CITY OF STOCKTON P MIT# 13 <br /> LABORATORY NAME COUNTYCZ; PHONE# _ <br /> SAMPLING FIRM A PHONE X <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- — Qin Opp GASQLTNF <br /> 39- 10,000 rAsni TNF <br /> 000 GASOLINE <br /> 39- <br /> 39- <br /> a9- <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 AGENT'S 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 C4LIFORNIA.' 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 /> W9MER'5 tVPI!N*ATION LAWS OF CAL17S 7A." <br /> an <br /> APPUCANT$$IGNATUR ITl_E96dMER ome /�'11-7=37n <br /> 0 APPROVED ❑APPROVED WITH CONDITION(S) Ll DISAPPROVED <br /> (SEE CONDITIONS BELOW A141XOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DA- <br /> ANY 09VIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> EH 23 046(REVISED Datt 3/B9) Page a <br />