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V' I � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND 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 THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOU_ <br /> VREMOVAL TEMPORARY CLOSURE �- CLOSURE IN PLACE <br /> EPA SITE # C,42hr DO// O1p A PROJECT CONTACT & TELEPHONE #Ed n� n UnOC� 6-/0-2,47-Z3l l <br /> F FACILITY NAME 'Formtr l�,/Lq Cfwl' Se! Z.L, b 0717-� /C PHONE # lqA <br /> CA p ,(I ,I <br /> I ADDRESS I03Li G2.w�y..71 Av-p- Tro,c CA <br /> LCROSS STREET lrt� cs+^�� <br /> T OWNER/OPERATOR ��qq nn PHONE # <br /> YI Forr erl O Grave b Vd10Cy� Gor or Ib✓T 5(O - 2��-2311 <br /> C CONTRACTOR NAME Arm�.,.1 �n i rltU',h PHONE # 9/(v -G 3/- /(p <br /> � 0 q <br /> i N CONTRACTOR ADDRESS 'IZ9 C4/DYha 2An C,6CAfL{W CA LIC # 59'ZoIO <br /> CLASS I <br /> T I <br /> R INSURER 01c(PAT CC. lE Xyl ur,4iicC GoMiA)l HORK.COMP-#A/WL 302LIS(-( <br /> A <br /> C FIRE DISTRICT C + o l_ <br /> r at PERMIT # <br /> C LABORATORY NAME S C VO i d. moth QX 1-6/ i�GS PSE # L99 4D <br /> R -I� <br /> SAMPLING FIRM QA0tkt SAV11f0V 11%&JC'k &tVI .TLC- PHONE # yog- `{y(-,75oo <br /> i IK ID # TANK SIZE - CHEMICALS STORED CURkENTLY/PkEVIW LY DATE UST INSTALLED <br /> 39- D / C) .%ol v.c Ittided /unieudr�/ lgZl . <br /> A 39- <br /> N 39. <br /> K 39- <br /> 39- <br /> 39- <br /> ���� <br /> IP <br /> L PPROVED APPROVIMWITH CONOITION(S) DISAPPROVED <br /> A SEE WITH CONDITIONS) / 1 <br /> N PLAN REVIEWERS NAME DATE <br /> ln 111111 111 ��l�ll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> CU <br /> SAN JOAQUIN CNTY 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 1N 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 /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF <br /> APPLICANT'S SIGNATURE: HG%%�f �OC IIS\L)1L lb� TITLE rO, 1. O L DATE O lO t <br /> SU <br /> EH Zi 046 (Revised 4/26/94) Page 3 <br /> v "e W02i� WV6Z° tl 9661-58-L <br />