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EWIRONMENTAL HEALTH DIVISION I <br /> APPLICATION FOR UNDERGROUND TANK M=R" PERMIT <br /> APPLICATION FOR PERMANENT/TEMpORMy CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DQ NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT <br /> TYPE BELOW: <br /> I REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> IIk . <br /> EPA SITE # C�C QQO(p�q O�O PROJECT CONTACT & TELEPHONE #I <br /> r ;6��H�R <br /> F FACILITY NAME , <br /> A R 1 PD N d f (&Q 5C� t�r (L7 iP PHONE �` <br /> iADDRESS <br /> L CROSS STREET vl J� h Tf <br /> AIN S72�Er ;a <br /> I <br /> T OWNER/OPERATOR PHONE !! <br /> Y c too/V (pi <br /> UA p-5D ��oL- D( S-TRC i3 2D9. 599, 2/3 /CT <br /> C CONTRACTOR NAME G,D �� PHONE # <br /> 0 ,h <br />` N CONTRACTOR ADDRESS L�3 u��� R �,y�.�T CA LIC # <br /> T Ll 1'�� 't'T arT <br /> R INSURER (IZAA/SA-m EiZLcor lik W <br /> O <br /> R <br /> K. <br /> P-0 <br /> A t ��77 I <br /> C FIRE DISTRICT e( /� o� f�rG� r PERMIT # f� <br /> T _/ C/ rf <br /> 0 LABORATORY NAME E�RN�kt.L(ZtC.L}L PHONE # <br /> R 26 D <br /> I S Z o90 <br /> SAMPLING FIRM 1-tTIC�y L }f PHONE <br /> III lI III 111111111 IFI li IIIII111 L ,c l <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- ..7 a 4/ <br /> T 39- I'F <br /> A 39- <br /> N 39- 'I <br /> K 39- <br /> 39- <br /> 111IIIlIIlI111I1II11II1I1111I1 lli IIIIIIl1111111111111111111111111111I1IIHII1111111111IIIlIIIIIIIII IIIIIIIII IIII11111111 <br /> p �1 <br /> ik <br /> L APPROVED _ APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A CSEE ATTACHMENT WITH CONDITIONS) p <br /> N PLAN REVIEWERS NAME H DATE <br /> 1[1 lI 111 Ii llI I1 II III Il 1I11111I II IIl it 11111111 11111!1111 11 I11 II IIl 1I 1111111 11111 11111111 Ii II 111 I1 lII Il I11111II 11 II 111 Il li 1 <br /> K <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTrS SIGNATURE CERTIFIES THE FOLLOWING- "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY iilmY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN . <br /> "I. CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i{I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE ii �SI�/J1��t/� DATE <br /> I <br /> EH Z3 046 (Rev 2/8/91) ft Page 3 <br /> Vu <br />