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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />%C REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # eqS g OSPI 2 <br />F FACILITY NAME Mi %;'I(evy 40e <br />A - <br />C ADDRESS O®o , o <br />I <br />L CROSS STREET A,1r Ov t IA✓G <br />I /T <br />T OWNER/OPERATOR <br />Y <br />C CONTRACTOR NAME e <br />0 <br />N CONTRACTOR ADDRESS 306 O <br />T CAi eo � C <br />R INSURER&c ro e a <br />A <br />C FIRE DISTRICT /I'iD+77t 241w4 <br />T <br />0 LABORATORY NAM Xce de M Ar <br />A. SAMPLING FIRM <br />Illliflllllililllllf11111l1111 � <br />NK ID # <br />39- Z ^ Uy Q <br />T 39- , 05 <br />A 39- _ <br />N 39- _ <br />K 39- _ <br />39- <br />39- <br />P <br />9 -39- <br />P <br />L <br />A <br />I <br />PROJECT CONTACT & TELEPHONE # CuleT A'Je'� c`U ?o9rr3 <br />o 4 ! <br />Sloe kfc,, A19SF <br />PHONE v'tp99-.S' j <br />PHONE # <br />n 4 Se r✓i°e es I PHONE <br />,e 4�z-n I CA LIC #.4-7/<-a�%, CLASS A <br />u�'Qntc �v�olfcevt <br />re Q 's ✓e c7l Ir/� <br />I 4 �s COI TY PJB®� <br />"em� <br />TANK SIZE <br />ovo_ tea[._ F. -bee` <br />WORK.COMP.# <br />PERMIT <br />PHONE # / <br />PHONE PHONE # <br />�I�I S STORED CURRENTLY/PREVI <br />c.._ a n..: _J -ro. c- <br />_ APPROVED WITH CONDITION(S) _ DISAPPROVED <br />SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />6 <br />l4 <br />�oov 5� <br />fG> 773 •3d, ``/ — <br />OUSLY DATE UST INSTALLED <br />N 16 z o <br />PLAN REVIEWER'S NAME DATE <br />gild, "I'll11111111111111111111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: R6 L -p / a Aayy Z c /� TITLE/a�"ac /�i.rr �sr� DATE !I-aG "e%7 <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />