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12/18/98 FRI 09: 30 FAX 5(106096304 RHL DESIGN GROUP RHL PET.aLMk Q004 <br /> SAN JOAQU..q COUNTY PUBLIC HEALTH SER\,.-ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT C <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE. <br /> P6 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE#CAL DDI 2Jo 3-71 PROJECT CONTACT Z E T T ROV LW N D PHONE# 925- 757- I i 9S <br /> FACILITY NAME TF-" PHONE# <br /> ADDRESS 4 LI.O Ili. C- \or+cr Wa SToC-XTorJ <br /> CROSS STREET <br /> OWNER OPERATOR Q,-Al LOfJ £r4-r ISES PHONE# q2S- 7 S7 !q9S <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME VE . Cur T2A[„ y ort PHONE <br /> CONTRACTOR ADDRESS 1400 OLS Cone-;o e-,Jbur:• ?ak-'k- CAuc# Z173700 1 CLASSA Naz P, c <br /> INSURER Ao„ WORKER OMP# W95AIG?oj <br /> FIRE DISTRICT 5 TO kT0 Q PERMIT# <br /> LABORATORYNAME eQNo A Ae-a Tvcd COUNTY 5G„ W-4eo PHONE# CoSD -36`(- 9600 <br /> SAMPLING FIRM CoLw,lof-ia PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- ,-- -L; CP I O Doo DI <br /> 39-jn5il- c) -1 ol OD40 Gct.5 <br /> 1 39- ;C^ - t V ooa UV\1elia u <br /> 39- - 2 ODD �.1+n1•e dad bas <br /> 39 <br /> 39- <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 AGENTS 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 CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE `^`�Lc%E=' � TITLEPrc��CG� �Cl✓1�+�Q/ DATE IZ ISS �� <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM "1 �' DATE <br /> E <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> hoox's In <br /> i <br /> -1 <br /> 3 <br /> C t U <br /> EH 23 046(R ED 10/19198) Page 3 <br />