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11/02/2001 10:47 9166813L31- GEOFON INC PAGE 05 <br />40 0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL. HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />RDOUS <br />- THIS PERMIT FORSTORAGE TANK(S) EXP RES s0 DAYS OFROM THE APPROVAL RARY CLOSURE OR ADATE, 00 NOTBANDONMENT IWRITEG N ANY SHADED AREAS- F OF UNDERGROUND INDICATE PERMIT TYPES <br />EPASITE# <br />FACILITY NAME D F <br />ADDRESS 70 (tel <br />CROSS STREET <br />OWNER OPERATOR <br />CONTRACTOR ADDRESS <br />INSURER rA< <br />FIRE DISTRIC <br />I ARC)RATORY NAME .S <br />❑ TEMPORARY CLOSURE <br />FACILITY INFORMATION <br />PROJECT <br />CONTRACTOR INFORMATION <br />j-)'4 GA LIC # <br />WORKER COMP# <br />9'y y z PERMIT # <br />2 r COUNTY .S�,4L.E°141�tNV <br />Il CLOSURE IN PLACE <br />P_HONEb, j� —3 6 <br />PHONE #�Q 4) 2"39.-Y.. 2 V n/_ <br />PHONE #C !6 s7� LA <br />CLASS z <br />0 1 I ST"9 <br />PHONE # %P/la f _7 ;, r6 do <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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 11 <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 />7T'HE FOO OWSNC�E CERTIFY' THATCT TO RIN THE PERFOTION LAWS RMANCE OFOF CALIFORNIA-" CONTRACTOR'S HIRING OR THU WORK FOR WHICH THIS PERMIT IS ISSUED, SHALL EMPLOY PERSONS SUBJECBCONTRACTING SIGNATURE TFIES <br />TO <br />WORKER'S COMPENSATION LAWS OF CALIF IA' <br />APPLICANT'S SIG9NATURE� <br />�4` TITLE DATE ✓ 0 <br />❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(5EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME OATEN <br />ANY DEVIATIONS FttOM TN.IS APPLICATIO MUST EI USMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />046 (REVISED 08/13/89) - Page <br />