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P <br />I <br />P <br />N <br />G <br />• <br />0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />,S� ppi�j fhq, <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND r aSSkN�FA E TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />✓ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE #Cq 167a8905.2-2- <br />PROJECT CONTACT & TELEPHONE # Curt I-OnCe- C-209) 983-5.331 <br />F <br />FACILITY NAME SfaCb. -dh Pi -my fiYla' oh <br />PHONE #(d0g) y83 -_530D <br />A <br />-Suppokt <br />C <br />I <br />1 <br />ADDRESS 2000-ST/h'1SOYi �d•, -S j-oo_h j6Y) C)q 9,6a06 -3997 <br />L <br />CROSS STREET q l r okt Wa <br />I <br />T <br />Y <br />OWNER/OPERATOR /1 1i O » '� <br />a firvn,(. 4a�ohal Cruafal <br />PHONE # <br />( 9/6) 8-,5�-395 <br />C <br />CONTRACTOR NAME C� Ghee.n C.O <br />PHONE # (9/6) Q:39 _G l qC <br />N <br />CONTRACTOR ADDRESS �0$8 ��/�Sq�r�(c, C/Ic(v �`/,l�orad, till <br />CA LIC # CLASS <br />X9.3.3227 <br />T <br />R <br />INSURER <br />Q! e Fund <br />I WORK.COMP.# <br />A <br />-5 <br />C <br />FIRE DISTRICT <br />( PERMIT # <br />T <br />0 <br />LABORATORY NAMECP Lp,6 SE,0Y/C6S <br />COUNTY .SQChQYYIG'{1 o <br />PHONE # BOO (0.3,7' ?30l <br />R <br />SAMPLING FIRM Cf4 LAAS SE.,FV/CE,S ( PHONE # 800 6a(? 7_ o/ <br />11111111111111111111111! 11 i l l l <br />TA" -if) -#p;hq T*Nf SIZE CHEMICALS STORED CURRENTLY HS <br />VIOUS DATE T 'INSTALLED <br />39- a f <br />T <br />39- <br />101 un fah r ass <br />'PFS Jtx FUEL <br />39- <br />39- <br />K <br />39- <br />39- <br />P <br />111!llllllllllililll i�111! 1 111111 I IIII111! IIII1111i1l1! 1111iiilllill111111lIil Illllti llllli111111111lillllliilllll <br />L <br />_ APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A <br />_ <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />(� <br />PLAN REVIEWER'S NAME"� DATE <br />Ilillllllll111111111l111111111l1i11l111l111111111111111111iililllllllillll11111l1l111111111111lllllllll1111111111111111111111 <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 <br />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 />j <br />APPLICANT'S SIGNATURE: TITLE / ! l � _ DATE <br />lf p 91— <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />