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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />T <br />A <br />N <br />K <br />WN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATIOti 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 />YREMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # C/7 Tfi1 i0 — PROJECT CONTACT & TELEPHONE # OA16 Sgwp-p, FAL-1 70, /r� <br />%r✓" 9460 <br />FACILITY NAME l�fl"ao SS . . ciS 4Q PHONE # ?�j- 218 <br />ADDRESS��Do �1J <br />CROSS STREET P l Ulm. <br />OWNER/OPERATOR- �tNC-Ili COkS ieo _n��1 �� �I i/�o PHONE <br />CONTRACTOR NAME -�.:v PHONE # g - 541 - '3 to <br />CONTRACTOR ADDRESS P05 14.0 -5 � Lo r <br />.71 gSIL4i - CLASS A � � C4fl, "AT. <br />INSURER GarL(�C�N(� Ihl$ul2�WG� W COMP.# Wgel 5j4ocx:)I <br />FIRE DISTRICT WAISP-Loc) , <br />iM112-/S•DA <br />_ PERMIT # <br />LABORATORY NAME J (fa 0Q1D► Apb L`fr1(,At_ I COUNTY <br />►t\i wl p PHONE # <br />'415 36¢ <br />SAMPLING FIRM 'rDU C.l-I <br />PHONE # <br />701 - 71.5- Go'? <br />11111111111111111111111111111 <br />TANK ID # <br />TANK SIZE <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE,4SS STALLED <br />39- <br />lo, cow <br />064OL04- Ut4 <br />39- -- <br />1 , coo <br />0 <br />l <br />39- <br />39- J o -1 /_- <br />O <br />Jr6co <br />.- <br />IJA SM — N�0 0 1 <br />L l 9 <br />39- <br />39- <br />39 - <br />III <br />-PL <br />- L APPROVED K APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N' <br />PLAN REVIEWER'S NAME �� n✓j ��J �✓[ CGS DATE (/ <br />�IIIItit111111111111111111111111111111111111111111111111111111111{IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII III111111III III <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: -� .�, � 'o' TITLE Y �07, /KGr DATE <br />CONDITION(S): o p 1✓ Pr� « �%� Q om ` <br />o� f� <br />-rig to <br />Ta4..k -s-uA,,p--- <br />EH 23 046 (Revis /11/96) Page 3 WL_ <br />