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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNOERGRCUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM TH PPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE 0CA p -Z,M-1 <br /> PROJECT CONTACT 8 TELEPHONE # I <br /> F FACILITY NAME PHONE # <br /> C ADDRESS (e40 <br /> I <br /> L CROSS STREET <br /> I PRONE <br /> T OWNER/OPERATOR <br /> C CONTRACTOR NAME �� s '�� I PHONE <br /> 0 c CA LIG At 'ate GLASS CtPl .L1{- Z <br /> N CONTRACTOR ADDRESS <br /> T I WORK.COMP.# Z <br /> R INSURER LF J '_ <br /> A I PERMIT # - <br /> C FIRE OISTRICIr o <br /> T PHONE #s�.. <br /> 0 LABORATORY NAME MC ' _ <br /> R � G <br /> SAMPLING FIRM V (�IE�GCL\i\iz PHONE # �S� Z'6z <br /> II"II,I""""Mill II TANK SIZE CHEMI LS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # L <br /> 39- G C '-tJ I 2.S'D tr11 tlfw4 "'� <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 139- i �i IIIIIIIII IIIIII 111� 11 11 11 111111 <br /> L APPROVED APPROVED WITH CONOITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> N PLAN REVIEWERS NAME <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, ANO R REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> ETHE PERFORMANCE OF THE WORK FOR WH CH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SIBCERTI FO 510ATERNSTHEPER ORMA CE f OTHE WORKO FORAWH[CNOTHISCPERMITX[SINSSUEDG OR �BCSHALLCEMPlOYSIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTHE <br /> WORKERFOLLOWING: <br /> COMPENSATION LAWS OF CAL RNIA " <br /> APPLICANT'S SIGNATURE: TITLE 1 � F'''it` , 'k �`�DATE <br /> cGlji.i+w(-�- . l <br /> EH 23 046 (Revisetl 4/26/9/4) LV Page 3 <br />