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' / /✓ <br /> 771 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> " APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURRF OR AP.A."^^!-LEMY IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FRCN TF�E�AP APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> ✓_/REMOVAL _ _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE YC g PROJECT CONTACT i TELEPHONE NF/N//LG ?U( <br /> F FACILITY NAMES` . ��. r124,12 7 _ '. ,� ' PHONE <br /> A / L <br /> C ADDRESS <br /> L CROSS STREET �. f.✓L <br /> i �1✓ <br /> 1 OWNRATOR / ------ <br /> Y .. z(9:� qlov— <br /> CO CONTRACTOR NMI _. C_[- C �� PHONE 02'09- <br /> N CONTRACTOR ADDRESS /l) .i-N V —`7— CA LIC /,ems,QS CLASS_ ' <br /> ( <br /> / <br /> INSURER �.� X� — X, WORK.COMP.NS J6 ,r " . 1 <br /> ,A Y I _ <br /> C FIRE DISTRICTG` IT 6 �o `tea c- •'� PERMIT N <br /> T — ..__. <br /> 0 LABORATORY NAME C�VI,L . ,ALS4Mt CA L PHONE <br /> R - -_. <br /> SAMPLING FIRM PHONE <br /> _- ununnnnnrnnnnnur -- <br /> TANK 1D CNEMICA�S�]I TTS�,CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 50 <br /> 39- 37- o1 C <br /> 1 39- <br /> A 39- ...__._ <br /> N 39- <br /> K 39- ---—__ <br /> 39- -- <br /> 39- .....___ <br /> n rr mrrrrrrrrrmrm H <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A ( TACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME -�- � � f DAYE - ' y- 9�i <br /> ,nnunnnnnnr unrrmmmrmmrmrrrrnni <br /> APPLICANT MUST PERFORM LL WORK IM ACCORDANCE WITH SAM JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY IC HEALTH SE CESr--OWNE LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF E 1KIRK FOR C HIS PERMIT I SUED, 1 SHALL MOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER` COMPEMSATI LA F CALIFORNIA.• TRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT 1 THE PE FORMAN 0 HE WORK FOL WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS Of CALL NIA. <br /> APPLICANT'S SIGNATURE: - TITLErlf-�' DATE <br /> LII 23 046 (ReVlced 7/10/92) Page 3 <br />