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0 0 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PUCE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO MDT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE __ CLOSURE IN PLACE <br />EH 23 046 (Rev 2/8/91) it Page 3 <br />EPA SITE / �C <br />PROJECT CONTACT L TELEPHONE t1f/GHgjPD //'9//1/LTDA/ 211957K 965-3 <br />F <br />FACILITY NAME i•Q/,oprt/ Illvu-1416 <br />PHONE t Z°9 S99 'IZ6?- <br />A <br />C <br />ADDRESS 'j'f SOUTi� S/-�'•�`LON <br />I <br />L <br />CROSS STREET 3.20 STeEc--% <br />T <br />OWNER/OPERATOR p <br />PHONE ! ZOG% <br />C <br />CONTRACTOR NAME <br />PHONE ! 2 p c :52 <br />0 <br />N <br />CONTRACTORADDRESS G�L3/ <br />CA LIC I �!/(CJ�6C� <br />/ <br />CLASS <br />R <br />p� <br />—DD� <br />INSURER i /7 �%NS ���� 1 G �7 <br />NORK.COMP.! <br />A <br />C <br />FIRE DISTRICT (� <br />�/�/ DF �/�j{� <br />PERMIT / <br />T <br />0 <br />LABORATORY NAME GeO AtiA�yT/c�L <br />PHONE ! 20%Z D9O0 <br />R <br />pi EO 9�igG y7icyL PHONE 0 20/ 57-2 1 9� <br />SAMPLING FIRM <br />TANK ID 0 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T <br />39- likl-� <br />0000 C��O'� <br />/ESEL <br />A <br />N <br />39- <br />39- I <br />K <br />39- <br />39- <br />39- <br />������������������������������Hill ilill11111111111111111 <br />L _ APPROVED _ APPROVED NITN CONDITION DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) -.- <br />N • PLAN REVIEMS NATE '� I- - :/ DATE <br />nn(1Uantlllna11nnn� 11111111111111Hill 111nf111111111111111111aII1111111111o11111111a11111111om111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAIUIN C"TY ODINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A KANNER AS TO BECOME <br />SUBJECT TO WDRKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"1 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 />A I ,, <br />1/�V�LC <br />TITLE 1 � PA • DATE �o� �9,;?d <br />APPLICANT'S SIGNATURE' 11I✓�"� <br />EH 23 046 (Rev 2/8/91) it Page 3 <br />