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.-1V <br /> 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 CF 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 #CSI I(p q` I j E of PROJECT CONTACT 8 TELEPHONE <br /> F FACILITY NAME C_(J -j, PHONE <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET L°'SIV <br /> I <br /> T OWNER/OPE TOR a PHONE # <br /> Y . () <br /> C CONTRACTOR NAME r�p (?j PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS )� J (C LuY'v CA LIC # CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAME COUNTY PHONE # <br /> R <br /> SAMPLING FIRM PHONE # <br /> TANK [D # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- n--<- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> p <br /> L _ APPROVED _,gyp/APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME C� DATE <br /> IIIIIIIIII[III IIIIIIIII IIIIIIII111lu <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: "I 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 FR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATJ6@: [ TITLE DATE <br /> CONDITION(S): <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />