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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TA�YK 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 />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # CAL 0 0 2118 2 0 8 I PROJECT CONTACT & TELEPHONE 'Bob Oliver 925-417-7403 <br />FACILITY NAME amen, I PHONE 9 <br />! I ADDRESS 110 We rNirner Road <br />L I CROSS STREET Woodhaven Lane <br />I - <br />T OWNER/OPERATOR PHONE <br />i Y AT&T 888-835=5347 <br />C CONTRACTOR NAMEKvaerner Aronson, Inc. ( PHONE 4( 916) 631-1646 <br />0 <br />N CONTRACTOR ADDRESS CA LIC "�gi�1 n CLASS A -B -C.10 HaZ <br />T 11297 CoT a Rd_ <br />R INSURER National Union Fire Insurance Co. of PA I WORK .COMP. RMWC2179955 <br />A <br />C FIRE DISTRICT PERMIT 9 <br />0 r LABORATORY NAME Welk Lab COUNTY I PHONE # 626-336-2139 <br />R <br />SAMPLING FIRM ATC PHONE # 530-878-6001 <br />� 1111111lI11111111111llllllltll <br />39- <br />TANK ID`. TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY I DATE UST INSTALLED <br />T 39- 3 5, 000 Q I I on I I <br />A 39- I <br />u 39- <br />39- <br />39- <br />39- <br />P <br />9- <br />39- <br />39- <br />IIlIlllllllllllllllll llltlllllll11111lIIlIl111111Ililllll^llltlltll11111 111111111111111111111r1111111111111(11111111 <br />L _ APPROVED APP W <br />V I CONOITI (S} _ DISAPPROVED <br />A (St-= CONDITIONS 3ELOW AND/OR ON ATTACHMENT) <br />� N <br />jPLAN REVIEWER'S NAME ( DATE <br />11111111111111111111111111illllltllllllllll111111111111111IIlllllllllllllllttllll1111111l11111111l1111ttt111t1U111111111111! <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF i <br />SAN JOAQUIN CCUNTY 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 3ECOME <br />SUBJECT TO WCRKER'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 PERSCNS SUBJECT TO '»ORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE /�"'�� OATS !f i��a- e.-eAAe4 6? <br />CONDITION(S): ItfVq—F r <br />fC <br />Am <br />T <br />eq <br />EH 23 046 (Revised 9/11/96) Page <br />®r a- QIiP •• <5A70:j 7 <br />J 8 <br />r <br />