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r. <br />• � � 3v1 � 3 • �V 1 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FCR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNOERGRCUHO HAZAROCUS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL _ TEMPORARY CLOSURE —_ CLOSURE IN PLACE ' <br />u <br />E:H 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE X (��ili�Q� QQS"�7��Z <br />PROJECT CONTACT L TELEPHONE 0P1(- ?(FFIN ' ) 5,,2.q -46r3 <br />F <br />FACILITY NAME 17.-t�RjH An.LLLItJ <br />PHONE #(zL q)�17G,-.gZL-7 <br />J <br />CADDRESS <br />I <br />I <br />L <br />CROSS STREET <br />I <br />r <br />Y <br />OWNER/OPERATOR,( <br />�I Po u V i. L LU. SZ <br />PHOONE 9 <br />&oV S" J el — —I J7 <br />C <br />I CONTRACTOR NAME <br />PHONE 'W 7p y f! g6S3 <br />0 <br />4 <br />CCNTRACTOR ADDRESS /Z/S/GY,sTH (, cA LIc x 9865/ Class ,g/,r?[, C6//O)eo <br />R <br />INSURER A/A��DDe/SYO/l, <br />iC <br />FIRE DISTRICT (� 1 fY CSP !Z(f aN <br />PERMIT 0 <br />r <br />'.ASCRATCRY NAME 6EOArv4Z,4 TVCil-[.- L�AP19e97oel�s <br />PHONE 0 ?1:1-7J!'�z 0900 <br />SAMPLING FIRM &0 N?.L. 1/%/C,Q-� /�430/2,j T(%e/SS PHONE # 209 �7Z 09Q(J <br />I I I I I I I I I I I 111111111111111 <br />TANK 10 '+ TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSi aLLEO <br />39- <br />r <br />39•PUP <br />—Cl <br />t g <br />l <br />39- <br />1 .e <br />39- 1 Li ir 1 —0 2 <br />0, POO L <br />1 <br />C <br />39- <br />39- <br />39- <br />Illllllllllilllllllllllillllli II1 it Il 111111 I I II II II II I II Il II !I ! FTFITI111111 III 111111 I IIIIIIIIIIII <br />P <br />L APPROVED APPROVE VITH CONOITION(S) DISAPPROVED <br />A E AT NT WITH CONDITIONS) / p <br />N PLAN REVIEWERS NAME DATE !� / <br />11111111111111111111 IIIII <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO REGULATIONS OF <br />SAN JOAQUI,N COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT 1.4 <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO SECCME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWINC: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO W'ORKER'S <br />CCMPENSATICN TAUS OF CALIFO IA." <br />APPLICANT -5 SIGNATURE: / "� TITLE <br />u <br />E:H 23 046 (Revised 7/10/92) Page 3 <br />