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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTFrEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK)EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> 7 REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY� INFORMATION <br /> EPA SITE CA R00014119 11 PROJECT CONTACT A/'//Yi46 g14'4bE,2j I PHONE# 6h/--250 - 9300 <br /> FACILITY NAME TE�20 USA W&8147-0 1 PHONE IF 6&-2 5 -93ov <br /> ADDRESS 13975- F A"AA1 88 <br /> CROSS STREET <br /> OWNER OPERATOR Tib oaO PHONE# 925-6 87- 27 S 3 <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME A73c� mN YA/TE'NAA7Ctr v y-yo3 PHONE# 707- Sys'15;.1) <br /> CONTRACTOR ADDRESS 3;15( RC' ,ONiOL /'KWySANrF/rnsA,[A CALIC# 372 V/5/ CLASS <br /> INSURER fl«'^a �A'T1'A�V/--'J IW'-.DOC-. WORKER COMP# WPI-5000 C+0301 <br /> FIRE DISTRICT i PERMIT# <br /> LABORATORY NAME - 7D ZO 7- r-- ,h//5Y� COUNTY PHONE# <br /> SAMPLING FIRM 7-0 6 B .D-72:10 ^/up I PHONE# <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT AND PAST DATE INSTALLED <br /> 39- ! /0,000 �yA'Sp- A <br /> 1990 <br /> 39- 2 /0, 000 q-6o64A1,- /990 <br /> 39- 5 /6, 000 6,0-SOC4Ak-- 19,70 <br /> 39- <br /> 39- <br /> 39- <br /> APPLICANT MUST PERFORM ALL NARK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE <br /> FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO BECOME SUBJECT TO WORKEggS-COM NSATION LAWS OF CALIFORNIA^ CONTRACTOR'S HIRING OR SUBCONTRACTING <br /> SIGNATURE CERTIFIES THE FOLLOWING: -AE 'IFY THAT�PI�NE THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKE 'Si O ENSATI N"LAWS OF CALIFORNIA.' <br /> Pi20J�cr/Y//�n/A�E2 ,Z 23 /a <br /> APPLICANT'S SIGNATURE TITLE DATE <br /> ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> E1123046 (Reviud8/I/II) 3 <br />