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C <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION OR UNDERGROUND STORAGE TANK CLOSURE PERAM <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSU OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. 0 ,NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />kc-. �&,j <br />EH 23 046 (Revised 9/11/96) Page 3 <br />�l%v� i �" fY� l✓v2`"�/� r <br />of ti <br />EPA SITE # ��O C <br />PROJECT CONTACT & TELEPHONE # tC�� ( '�V��/1 2a9•T- <br />FFACILITY <br />NAME <br />r�sc` f <br />PHONE �L <br /># /U� � /��( <br />A <br />C <br />ADDRESS ' v <br />I <br />L <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />�=�D 714-- <br />PHONE # <br />2� �Z I <br />Y <br />-4 <br />C <br />CONTRACTOR NAME <br />G ---la <br />PHONE # S ,Qj3 <br />N <br />CONTRACTOR ADDRESS o <br />, <br />CA LIC # '7 � 3 3 (P � <br />CLASS ,e 6 <br />f <br />R <br />INSURER <br />safr C-0 <br />WORK. COMP. # Lj 0 00 <br />C <br />FIRE DISTRICT �( ' <br />PERMIT # �� <br />T <br />0 <br />LABORATORY NAME G��yrp�j <br />DU Y 1 _��,V <br />G Y <br />PHONE # ¢�n� 2 c�G�. • `'7')77 <br />c'� <br />R <br />SAMPLING FIRM �i� {YtOIJ <br />TAN ID #, <br />PHONE # 294 k 75fi� <br />CNEFIkCA�IS STORED CURRENTLY/PREVIOUSLY DA T INSTALLED <br />_L � <br />39- 0 <br />r <br />T 39- <br />A 39- <br />N 39 -t <br />- <br />K 39- <br />39- <br />39- <br />P <br />L APPROVED <br />APPROVED WITH CONDITIONS) DISAPPROVED <br />A <br />(FE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME <br />DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE <br />WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMA CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFO NI " <br />i <br />J ��pp `�_ Q <br />TITLE �►t DATE 19� " <br />APPLICANT'S SIGNATURE: <br />CONDITION(S): <br />kc-. �&,j <br />EH 23 046 (Revised 9/11/96) Page 3 <br />�l%v� i �" fY� l✓v2`"�/� r <br />of ti <br />