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<; <br />R� 4 <br />ENVIRONMENTAL HEALTH DIVISIONAPR 2 qg <br />APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT J ENT HEALTH <br />APPLICATION <br />FOR PERMANENT/TE Y CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND M IITY <br />Ais <br />THIS PERMIT EXPIRES 90 DAYi FROM THE APPROVAL DATE. 00 N0T WRITE IN ANY SHADED AREAS. IND <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE N PROJECT CONTACT a TELEPHUNE #B111 Bunch--(408)244-6739 <br />F FACILITY NAMEPHONE # - <br />Countr Club Shell <br />A <br />C ADDRESS 2575 Countr Club Stock <br />I <br />L CROSS STREET Interstate 5-W--W- <br />I I PHONE 0 <br />T OWNER/OPERATOR 2 0 9) 948-0574 <br />Y Steve riffin <br />C CONTRACTOR NAMET.L. Peirce PHONE # (818 ) 951 -7710 <br />0 CA LIC # CLA33 <br />N CONTRACTOR ADDRESS 7401 Foothill Tu' n CA - <br />T WORK.CDMP.# 446-9 U it00001 6 <br />R INSURERState Com en atio <br />A PERMIT <br />C FIRE DISTRICT <br />T PHONE # <br />0 LABORATORY NAME <br />R PHONE # <br />SAMPLING FIRM <br />lIIIIIIIIIIIIIIIIOI lIIIIIIIIIII TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39. 0 81 21 ql s <br />T 39- gjs 97nt-fi w3l e ded rsacnl ; np <br />A 39- 4 12 ai <br />N 39• a0 <br />K 39- <br />39- <br />P III! ITl <br />L PROVED R D WIT ITION(S) ,,,� DISAPPROVED <br />A (SE AT H T ONDITIONS) DATE <br />N PLAN REVIEWERS NAME DATE <br />}1!1'11 « 11111'1115 <br />tllttltllllllliiiiiiiiiiiii <br />I <br />APPLICANT MUST PERFORM ALL RN IN ACCORDANCE WITH SAN JOAQUIN COUHTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGi "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOt� WHICH THIS PER14I1 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A HAMNER A8 TO SES <br />SUBJECT TO WORKER'S COMPENSATI� LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; <br />i1I CERTIFY THAT IN THE PCRFORHANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />TITLE DATE <br />APPLICANT'S SIGNATUREa <br />i <br />EH 23 046 (Rev 2/8/91) ft Papa 3 <br />(Rev 4/8/91) <br />I <br />i <br />i <br />i <br />i <br />i <br />i <br />i <br />i <br />lJt� <br />d �b ; 60 E6/t x/60 <br />a , <br />