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RECEIVED <br /> JAN 21 2020 <br /> ENVIRONMENTAL HEALTH <br /> (�i ' <br /> PERMIT/SE�a t <br /> AN . IQAQU N Envlronmenta ea apeHment <br /> — COUNTY <br /> AP~'LICATION FOR UNDERGROUND STORAGE TANK <br /> C>L.OSURE FERMIT <br /> THIS PERMITFORPFi2AilANEPITIiEMPORARY CLOSUREORi1 NMMM904NPJACE•OF•UNOERGROUND HJ3AROOUS j <br /> SUBSTANCES STORAGE` TANK{SjjERPIREs'ISODAYSFROM THE APPROVAL DATE:- D0NOT-WRIT EIN-ANY-SHADED AREAS. <br /> INDICATE PERMIrTYPEf. <br /> 13 REMOVA lL ❑ TEMPORARY CLOSURE % CLOSURE IN PLACE <br /> FACILITY INFORMATMN" <br /> EPASITE# C&b04(53I15 PROJECT CONTA" E S /4- PHONE# Ig ok <br /> FACICITYNRME ' � - 'JG" 4l — ' .Flc Via . . . +.N DNe #2•[., = <br /> ADDRESS . a <br /> - - CROSSSTREET VW4 ✓ - 1 'g t ' •'� St ''... <br /> OWNEROPERATOR an"llis <br /> 1 <br /> CONTRACTOR INFORMATION <br /> � -CONTRACTOR NAME O PHONE# 7%G/ /5/b <br /> CONTRACTORADLJR S o (A/C�.9GI CA LIC # CLASS 19 j <br /> 'INSURER .L C 'e•3 =WORKER COMP# / 600s See +DsYVRvz�P�en '.,,.... <br /> .TIRED1SrRICT Td.✓ - - PERMIT# <br /> LAeDRATflRYNAME o , s Lzrigineering , Inc . iowwY Kprn TLWNE� <br /> SAMPUNG FIRM 'PHONE# GRI <br /> I I ' <br /> TANK INFORMATION i <br /> r3gu <br /> K ID # I TANK SWE TANK CONTENTS PRESENT ANDPA - - -DATE INSTAttEL -(900 Pe c I(i <br /> APPLICANT MUST PERF pM ALL WRK IN ACCORDANCE WTH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS, FEDERAL LAWS, AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENPS SIGNATURE CERTIFIES THE <br /> FOLLOWWG' T CERTIFYYHAT IN THE PERFORMANCE OFTHENDRK FOR WHICHTHIs PERMR ISISSUED.TSHAILNOTEMPL OY.AfMyF'ASOH INSUCH <br /> A MANNER AS TO SECQME SUSJEC7 N WORKER'S COMPENSATION LAWS EDF CAUFORNLV -CONTRACTOR'S HILUNG ON &S CONTRACTING <br /> Sjm"TURE CERTIFIESTJIE FOLLOWNG: 9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL <br /> EMPLOVPERSONSSUBJECTTOIM)RKER'S' .OMPEA Bt 'IAN50FCA19FS]RNIA.' <br /> APPLICANT'S SIGMA <br /> _TIRE DATE � �'"' 2 <br /> r <br /> I . <br /> ❑ APPROVED APPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> n (SEECONDITIONSB4.OVJANDIORONATTACHMENT) <br /> PLAN REVIEVVER'S NIIE tr' `'° "N DATE <br /> ANY DEVIATIONSFROM THIS APPLICAWONMUSiBESUBMI TED TO END.FOR APPROVAL PRIORTO COM90CM6WOFnC. <br /> CONDITIONS: <br /> 3 Of 10 <br /> i <br /> I <br /> I <br /> i <br />