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ENVIRONMENTAL HEALTH DIVISION ) i'�., 11 <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT l V <br /> FEB 28 1991 <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORRAAGGEggFACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS.IMDLCAINMWAL NtAL <br /> t Y VP�IEjRRMIT l SNE IRVICES <br /> REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE # ;�'(,.f,� �� 70940 PROJECT CONTACT 8 TELEPHONE # / <br /> F FACILITY NAME ' V'Z � 5 ��rd�� ` PHONE # 7/J O�l� <br /> A /rte„ 7- D <br /> C ADDRESS <br /> 1 bbbfff!!! <br /> L CROSS STREET / <br /> L% <br /> T OWNER/OPE A,T OR PHONE <br /> Y (1` - ,V 5o1/ 470c,617 <br /> C CONTRACTOR NAME T e �E1„lN .� PHONE <br /> N CONTRACTOR ADDRESS CA LIC # _S CLASS /,-/� <br /> T <br /> // <br /> R INSURER '�5�r�c:ri6r /�T-r�/� SU C ' WORK.COMP.# lo <br /> A l/ <br /> C FIRE DISTRICT ` PERMIT # <br /> T / \ r <br /> rod <br /> 0 LABORATORY NAME L ' PHONE <br /> R SAMPLING FIRM PHONE #I . CJ / /'V <br /> IIIIIIIIIIIIIIII 1111111 IIII / t/20 <br /> TANK ID # TANK SIZE -{ CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- Z51'7 r AAt.--6 54.0 vrf-srt or <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIIIIIIIIII1111111111111111 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIII111111Hill 11111111111 IIIIIIIIIIIIIIIIIIIII <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A �^/J ATT ENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME I /'IW (A TT DATE <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIII II1111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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 WOFOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." -� <br /> APPLICANT'S SIGNATURE: TITLE DATE GJ / <br /> EH 23 046 (Rev 2/8/911 ft Page 3 <br />