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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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELW: <br /> _ REMOVAL TEMPORARY CLOSURE _CLOSUR/E_ IN PLACE <br /> EPA SITE # ��qq (t C� PROJECT CONTACT & TELEPHONE #Gd QA IS}OA (Uhocc () SIO-Z?�--Z3 1•.t <br /> F FACILITY NAME rorme.r OAoc4kl JG(-V ICR- Z PHONE # �A <br /> A p �( <br /> C ADDRESS (0-3(4 c-e V jA4-r K RV t- r C-/4 <br /> I <br /> L CROSS STREET 1 t—,& S <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y -orywk rl coperalel QAo r a SIO- 2--7-LI kk <br /> C CONTRACTOR NAME - PHONE # c <br /> 0 <br /> N CONTRACTOR ADDRESS ";tq C,1 CA LIC # 2 20 O CLASS <br /> T 1 <br /> R INSURER (!. oldeir� FA I T SV N CAI,�.� WORK-GDMP.# AIWG 3029$1-03 <br /> A <br /> C FIRE DISTRICT �+ . PERMIT # <br /> T <br /> 0 LABORATORY NAME 2 0 A. F - PHONE # 5j() ,9 8 _ O <br /> R 1 n <br /> SAMPLING FIRM PALI Z.. G-IAV,ronv,nC.,,�aQ L PHONE # _ 41gl- VV <br /> 7-5-0,1 <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY PREVIOUSLY DATE UST INSTALLED <br /> 39- 55o A I10 Uc.sD111 39- <br /> le_d«1� 14_,/.,0 1A21 ? <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIII III 111111111111111111 111 11111111111111 111[Jill1111 11111111111111 <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER ON 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 /> 9 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 CALIIFO`RRNNfIA.-�_ <br /> APPLICANT'S SIGNATURE: < G TITLESrt, F-NV• C-XEb L- DATE <br /> EH 23 046 ;Revised 4/26/94) Page 3 <br />