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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNOERGRCUNO STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNOERGRCUNO HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> n z V REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> J EPA SITE : 1�.�' 1)39 I D PR//OJ1J��EC��T/� CONTACT d TELEPHONE d µnl�T {N (Zmr() SzY-4l.,t3 <br /> F FACILITY HARE I�epOLLLL�sfPUa � I.AVG &MttY PRONE �rT, 4t(-5-733-7 <br /> C AOOREss loepo E. �NrTr?l � ,7{i7(.IZ� G/�.. 9SLos, <br /> ' CROSS STREET Un I014 <br /> f <br /> f OWNER/CPERATCR �/ / PHONE 5 <br /> JI Y u �'IAtI t�l�lr (Loy) <br /> C I <br /> CONTRACTOR NAME Sa✓/1�LO PHONE Z�:I/ J!•"Zf( 96,5'3 <br /> N r.NrzAciDR ADDaEss /2/� Scr.TN 7�'� /ylo4eSY0, � cA LIc = S-'�'9865/ I cLAss,q�,3, <br /> muzsR C CLOC-A! �k6(..� Z+vSG1l2F1,UC•� ef7, WvaK.ccMP.s��G L`t�.sl�3-GY) <br /> zFile OISTRICi }.�[ D S Qt I PERMIT 3 <br /> r <br /> ABCRASCRY NAME 6eoLn,4z-4/T/C.YL 4;&zq-raP/Lf PHONE e ZO�I SQL d900 <br /> SANP'_!NG FIRMt"O kr.?c y-rle-tC 61'13O/Lq 7IJe/SS PHONE e Zd9 -47L apeo <br /> T <br /> IIIIIIIIII111111(Illllllllll <br /> TANNK !D TA�YX Sj E CHEMICALG 4TCREND REHiLT/P0.EV[OU LY OAie VST IHSS AL!-D <br /> I 39• C�wG Q�i�.0 I�HlGlls•.VM <br /> i 39 <br /> 39• <br /> 39- <br /> < 39- <br /> 39- <br /> 39- <br /> L <br /> 9•39L APPROVEDA➢PROVED WITH CONO(TION(S) _ DISAPPROVED <br /> A T -.ATTACHMENT WITH CONDITIONS) <br /> N PLAN RE`/1-UEH5 NAME + / + DATE 6 (D !J <br /> 11111111111111111111 11111ill III it 11111111111111 InT <br /> i <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOACUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> TRE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> sUSJECT TO VCRXER'S C.^•MPENSAiI LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLWINC: <br /> "i C-.iTIFY THAT IN THE PERFOR NC- Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER <br /> =-PE9SATICN LAWS OF C:.LIFO <br /> � / J <br /> APPLICANT'S SIGMA i URE: f'✓"�AG TITLE OA f � <br /> i <br /> CD.Frn oer �`ex,a o <br /> T.eS�� 7-PN- D 6 T E x <br /> .A 23 046 (Revised 7/10/92) Page 3 <br />