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i <br /> C) <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> HAZARDOUS <br /> ANCE <br /> TANK <br /> APPLICATION <br /> THIS PERMITOEXPIRESN90TDAYSP RC14 THE APPROVALADATE. M00 NOT WRITE IN ANY ESHADED DAREAS. INDICATE PERMIT To E <br /> BANDENT IN PLACE OF TYPE BELOW: i <br /> REMOVAL TEMPORARY CLOSURE __ CLOSURE IN PLACE <br /> 1 35 -2HH L' <br /> EPA SITE # CAVA gQ20511.132 PROJECT CONTACT & TELEPHONE # 1�� Nolln�n Cci 11c� <br /> PxoxE # (�j�q) y'13 -'133-! <br /> - L <br /> ACILITY NAME �,Jlollc' .1. S. <br /> DDRESS V.I. y1�rz1^ L_t, ' <br /> CROSS STREET In.�.zls -�y�'� <br /> PHONE # <br /> OYNER/OPERATOR <br /> „ PHONE it (QIb7c,2&- K3�� E <br /> CONTRACTOR NAME ,�y.-�L�a ���r CI <br /> T CA LIC # Lv Gt Y5 -T 'K -T <br /> ASS <br /> 4 CONTRACTOR ADDRESS 1 a I!.1 tl. pd',4->=fb <br /> _ I YORK.COMP.#a1„/G2,'INN 81n � L7 , <br /> i INSURER (�OIC.^r G e I PERMIT # <br /> TI FIRE DISTRICT [-' 1} cit' S�Cx%�"-�'�'^ I PHONES # CG>in-) le Lo 00 <br /> 0 3ORATORY NAME N Jia �,LS,r�-I 'L'�') <br /> R Tlb� L34 - 2 <br /> SAMPLING FIRM I�d I PHONES # O LE <br /> I IIIIIIIIIIIIIIIIIIIIIIIIIIIII TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE E INSTALLED <br /> TANK l0 # 1tl�O (a3l�ons �j L_S I 1� SZ <br /> 2- <br /> T 39- <br /> A 39- �- — <br /> N 39- ��- <br /> K 39- <br /> 39- <br /> 39- II I I III II i I VIII I II IIIIItIII II Illlll <br /> IIII DISAPPROVED _ <br /> P APP=SE; <br /> PPROVED WITH CONDITIONS) <br /> L � TTACHMENT WITH CONDITIONS) DATE <br /> A IIIII <br /> N PLAN REVIEWERS NAME <br /> 1111111111.1111111111 <br /> CERTIFY THAT IN <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SAN JOAOUIN COUNTY PUELI�CRKE HEALTHSERVICES. <br /> THIS PERMIT OIS ISSUED, AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br /> THE PERFORMANCE OF TO WORKER'S <br /> SUBJECT TO YORKER'S COMPENSATION LAVH OF CALIFORNIA-" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> SU CERTIFY THAT IN THE PERFORMANCE OF THE YORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> L <br /> TITLEIDATEDAT � <br /> APPLICANT'S SIGNATURE: Lp"`� <br /> � T�gVUl�7"o a'L/1 -30 /bS <br /> Uo o <br /> j Ae GamI . <br /> Page 3 I <br /> EB 23 046 (Revised 4/26/94) <br /> i <br />