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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> E1VIRONMEIITAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TAINK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/T'EXPORARY CLOSURE OR ABAHDCNREVT IN PLACE OF JNDERGROUND HAZARDOUS SUBSTANCE SiORACE TANK <br /> EXPIRES 90 HAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS INDICATE PERMIT TVP_ BELOW: <br /> �AEd40VAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE 0 R PROJECT CONTACT & TELEPHCNE 0 Rester -a764 <br /> F FACILITY NAME ' P+LONE ;97aq ?43 " `'�-1 z— <br /> C ZDRESS 3 sTA:�KTDA-), G4 <br /> I 4 <br /> L CROSS STREET NI6rh'%),t / �' ( /NElcJ7�+V )eD, <br /> I <br /> T I CUNER/OP=_RA-GR PHONE <br /> CECCfjINl, CEC<MI" Grou,�►v ucai / Seo - 75y/ZosB `! <br /> C CCNTRAC70R N„ME wWV'? /� p�/J(/fr�l/fry{�t flyG PHCNE �(; yj�o-'02 <br /> 0 <br /> H CCN T RACTCR ADDRESS M�v(�i L �f fJ CA L I C T �8�� ,� C-ASS <br /> /F6,3 �aY. r1 <br /> R INSURER <br /> A <br /> C FIRE DISTRICT Kf�} a�iuJ� �14 ?,KNIT `. <br /> 7 <br /> G LABORATORY LAME,41,C7#4 PHONE 7Q? 4lp$aC�O r <br /> R <br /> S„YPLING F,RM PHONE ; 7a7 �68-d <br /> Illill]!]llillllillllliflillll <br /> 4-0\ TANK SIZE CR ulCv4l5 STC4D CI;RREVTLf/FRGVI:.JSLY DATE UST 'NSTALL:3 <br /> 39- <br /> T 39- SS <br /> A 39- F <br /> 4 39- v <br /> K 39- Rm <br /> 1 39- <br /> !!11l11 rlltll lll]l111l1lllll 1 I !!1 111!1!! !]ll 1 1111t1i11 llllll IIII l! <br /> I <br /> P <br /> L AaFRCVED APPROVED WITH CCND'TICN(S) DIS.PPRGVED <br /> A (SEE CONDIT'CWS SELCW AND/OR OV ATiAC'iMEiTJ Q �] <br /> A �r 1_. <br /> PLAN REVi5uER'S 4AHE �1TE _ /J <br /> r11111(Ilit[I1Ill[111[t!1[1111[lllliltli]II111[illl 1! 1[i[IllIllllilll11t1111lllllllIlliIII IIIIIIIIIIIIfill IIlliIII IIIHI <br /> APFLtC-NT '{UST PERFOR4 ALL WR1C IN ACCCrT'3ANCr WITH S„N JCJICUIH COUNTY CRD'hANCES, STATE LAOS, hND RULES A10 R£CULATIONS OF <br /> AN .OA^-UIN COUNTY PURL:C HEALTH SERVICES C.rNEX OR LICEVScD AG'cYT'S SIGNATURE CERTIFIES TyE TOLLIsW!NG. "I CcRTIFY 7lAT :V <br /> THE -cRFOR'LANCE OF TyE JCRK FOR 'JHICi 71IS FEgMIT IS ISSUE-3, I SHALL VOT `.KPLGY ANY PEtSCV 'V SJC4 A MAhRF;t AS TO SECC E <br /> SuS..ECT TD WCRKcR'S CC."PEVSAT'CH LADS OF CALIFCRNiA.° CONTRACTOR'S 4IR'hG OR SUBCONTRAC73NC S4GNATUR£ CRT'FIES *HE FOLLCWI4C <br /> "I CERTIFY THAT IN T%E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS SSUED, I SHALL EMPLGY PERSONS S%µS; ZCT TO SZRKFER'S <br /> =4PE4SATiON LAWS OF CALIFORNIA <br /> APPL'C-.NT'S S&GAATUR« T T`Lc' Ik•�-�+ T DATi: ~l'/ <br /> COIF-DITION(S)- <br /> =l 23 046 (Revised 9/11-/90) Pace 3 <br /> d W06-3 IydZP 6 456 t–L 1-6 <br />