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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 BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # ' O b� PROJECT CONTACT & TELEPHONE # em CJIQLf 7 a48 <br /> F FACILITY NAMEArco �—`a 1b� PHONE # <br /> A <br /> C ADDRESS Lk4 � -bN A <br /> I <br /> L CROSS STREET 1 1 <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y k nur — C�rls� qce 45 3-)LFSS' <br /> C CONTRACTOR NAME ��.� PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC #70a a CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A \ /_ � 1 <br /> C FIRE DISTRICT C/' �/�/ I PERMIT #g <br /> T 1-10187 '` <br /> 0 LABORATORY NAME ?.O. f�OPc,Cp`1aY.ej�o.. ,/-)naa -TICe.Q 'C4 c16 PHONE if'c1Dg tF,37-01fUb <br /> R <br /> SAMPLING FIRM ���/y�yy��/{� Sit? / PHONE 9/b 9Z0:- V <br /> TANK IO # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- I (o 019-0 'Ke�i,�k.�, t~e.a_,.te�a 197y - ,4PZ,L- <br /> T 39- <br /> A 39- Q. PU-O eii�4'at�(.,6 <br /> N 39- ;O Oyv - 17 7 7 - J u;'+e <br /> K 39- <br /> 39- <br /> 39- <br /> iffilifillifillillillll! <br /> L PPRO APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) 2 <br /> N PLAN REVIEWERS NAME DATE v y <br /> APPLICANT MIDST 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 FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> `�/ <br /> APPLICANT'S SIGNATURE: -�/�L� cS(,RGfC� TITLE / !6 �O <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />