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10,'17/2000 09.00 2094683433 FIFTH FLOOR 'AGE 03 <br /> SAN JOAQUIN COUNTY PUBLIC HEALT14 SERVICES <br /> ENVIRONMENTAL HEALTH <br /> APPLICATION FOP. UNDERGROUND STORAGEIVISION TANK CLOSURE PERMIT <br /> WIS PERMIT POR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE <br /> STORAGE TANv-,(S)6XPIPSS 80 DAYS r-ROM-rHE APPROVAL DPiE DO NOT WRITE IN ANY SHADED AREADS IND CDA S PERMtT�RaES <br /> 0 REMOVAL. 0 TEMPORARY CLOSURE --CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> @PA SIT PROSECT CdNTACT <br /> FAC)UTY 1= PHCrNEic <br /> A,DDR SS 2 5 PACTFtr <br /> PHONE# <br /> CROSS STRar-T noi Jr-1 AC <br /> OWNER OPERATOR <br /> F'NDIVE fF <br /> CONTRACTOR INFORMATION <br /> 'TRACTOR NAA�{Fe <br /> -693-9 <br /> COJVTRAC7M ADORES Q f'Yi04�E M <br /> INSURER CA!1C# 'ICLASSA <br /> w RICER Ok4ft <br /> ✓=IRE DI RI <br /> LAWFLATORY NAME MPBELIPi-IONS f <br /> SAMPLING FIRM Q NTYPHONE A <br /> TANK INFORMATION <br /> TANK TANK SIZE TAN TENT'S RESENTS PAS DATE INSTALLED <br /> 53 -- <br /> G <br /> ASOLINF <br /> 10,000 <br /> 3[" 10 000 <br /> 39- <br /> 39- <br /> 39- <br /> AFPL'CANT MUST PERFORM ALL WORK;N A=ORDANCE Wrrm SAN JOAQUIN COUNTY ORCAYANCE$,STATE LAWS FEDERAL LAWS AND AULES AND <br /> -ALTH SERVICE!S OWNER OR CEERTIFY THAT IN THE R6RFOUIN COUNTY PU13LIC MF RMANCE OF T WORK FOR WHICH THIS PERMITS WULICI SSFIALL NOTMPLOY�ANY PERSOFIE N Eils+t S HE <br /> FOLLOWING AS <br /> Td BECOMe SLRJEC7 TO WORKER 8 COMPENSATION LAWS OF G4LIFCANW' CD TRACTOR S HIRII+:G Op$LM3CONTpACTWQ SIGNATURE OWINGCERrI7F 1 <br /> THE FOLLOWINCa- M C"kTIFY THAT 94 THE PERFORMANCE OF THE WORK FOR WHICH THIS P@RMIT IS iSSUEC,I SHALL.EMPLOY PERSONS SUB ECT TO <br /> WORKER 3 CAS ZNSAZION LAWS OP C.ALIPCF"A,' <br /> APPLICANir%SIGNATURE TtTLE OWN E.Rl DATE <br /> D APPROVED Q APPROVED WITH CONDITIONS) 0 DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ONAT7ACIiM1�-iT) <br /> PLAN I�E1ttEWER'S hIAME OAT!* <br /> ANY DEVIATIONS FROM TIiIS APPLICATWN MUST 8E SUOMrITED TO EHI7 FOR APPROVAL P8101COMMENCING WORK. <br /> CONDITIONS: <br /> Ef-i 23 046(REVISED(38f73199) pa$p g <br />