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!� {� <br /> ^i(N SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> HE PERMIT FOR PERMAMENT/TENPORARY: EOR ABANDONMENT IN PLACE OF t� HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN AMY SNARED MEAS. INDICATE PERMIT TYPE SELOW: <br /> REMOVAL TEMPORARY CLOS M yyCLL,O��SUUR,E IN PLACE y <br /> EPA SITE PROJECT CONT ACT E TELEPHaIE # 944- n � CQ 5Z4-Qb..f3 <br /> F FACILITY NAME {/AdAP 1- Pirwee xy PHONE 0 <br /> A <br /> C ADDRESS 0600 S- t�4/e.'L4�- ' �4 J <br /> Y L CROSS STREET <br /> T 011NER/OPERATOR PHONE 0 <br /> Y fferju-r}wAy, .t7uc. z,�►9) GvY-6?$7 <br /> C I CONTRACTOR NAME SEMM PHONE (209) 524-9653 <br /> N CONTRACTOR ADDRESS 1217 S. 7th St. modesto, CA 95351 I CA LIC N 449864 1 CLASS A,B,C61/D40 <br /> T <br /> R INSURER CalComp Jr StWat)Ce Coap <br /> Mny WORK- W964137662 <br /> A <br /> C FIRE DISTRIC � y _4L Jfu OU.V PRMIT d <br /> T <br /> 0 LABORATORY NAME Geaat33lyt].Cal LabS s <br /> R laws P!PHONE0 (209) 572-0900 <br /> SAMPLING FIRM Geowml PHONE M (209) 572-0900 <br /> Ifllllfill lIII <br /> f!°ltlflilltHltt <br /> TANK ID 0 T ICALS STORED CURRENTLY/PRE'/TCUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- 44 4 <br /> 39- 11fill TItIT( tTRiillTlninIII III <br /> P <br /> L _APPROVED APPROM NITR CONDITTON(S) DISAPPROVED <br /> A (SEE CON11tTIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAMEOV-01 DATE B <br /> zr4,&c2 <br /> 1111111 l III 11111!lltllllliUllllllltillllillltltllliJll111ifllliititlll111111111111111tltilfliltlllilitltitUllltllllllll 1 1 1 1 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WiTN SAN JOAaIiM COIAITI' ORDINANCES, STATE CAPS, AND RULES AND REGULATIONS OF <br /> SAN 1QAOUIN COUNTY PUBLIC NEALTN SERVICES. OWNER OR UCERM AGENT'S SIGNATURE CEIITtFTES TRE FCLLOWtNG: "I CERTIFY THAT IN <br /> THE PERFOMWICS OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SNALL NOT EMPLOY ANY PGWON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKES'S COMPENSATION LAWS OF CALIFORNIA." CO MIACTOR'S HIRING OR =CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING. <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WNICN THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF C5;: <br /> " <br /> APPLICANT'S SIGNATURE: C &L— TITLE 8.4, DATE <br /> CONDITIOMS): UrAlergrotmd Service Alert will be contacted at least 48 hours prior to start <br /> of excavation. <br /> --fes ILS v1111v5-FAt -bw4:4s mwcA- be- -e0qmfm'w qcc-oadlxv 4-0 CdA40- <br /> '�y <br /> J <br /> EN 23 044 (Revised 7/10/96) J Paye 3 <br />