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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />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 />EPA SITE # _' A p gP-3S -)S& g 'T <br />PROJECT CONTACT 8 TELEPHONE # <br />F <br />FACILITY NAME oko U eY <br />PHONE # L -o: 'c:__ <br />A <br />r / I <br />ADDRESS <br />(A J �YIL 'T(J"V 95Z15- -P U O <br />f <br />L <br />CROSS STREET - <br />I <br />T <br />Y <br />OWNER/OPERATOR <br />Al" U �or <br />PH E # <br />i�g ✓' Z61 <br />C <br />CONTRACTOR NAME S A G l G O � Life"-- <br />PHONE # %O g) - �-;z6 fv <br />0 <br />N <br />CONTRACTOR ADDRESS �t�� ./, <br />CA LIC # (,;o �/( <br />vv�� <br />CLASS C' �(�" A <br />R <br />INSURER S�-9.�e �% N <br />WORK.COMP.# /S /Z S'J-7/'f/ <br />A <br />C <br />FIRE DISTRICT e ''!hQ �i$ h; G.f <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME 9AjuiLhmq,COUNTY <br />Sq S ,,,N <br />J <br />PHONE # <br />R <br />SAMPLING FIRM F(, L LNV K,\j ( (�. �-AAW PHONE 0, �()r <br />f, <br />I I I I IIINII 111DI 11111111111 <br />TANK ID # TANK SIZ CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />FT <br />39- 1415? O .003 C/N I7L:'�7(`� CA'oiiA-P <br />39- — <br />;� ',co. <br />A <br />39- <br />T <br />N <br />39- <br />I j <br />K <br />39- <br />39- <br />39- <br />— 1111111111111111111111111 <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME 1 DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 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 MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I 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 />`7 `/� <br />JA <br />APPLICANT'S SIGNATURE: 1. JLIJLI Ate/ '4'6n o�� TITLE _ e � DATE a'Z(o Y <br />uu <br />