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s � <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CL—wr OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FR011 TNF.APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE BELOW: <br /> V/_# TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE YG,AGG� s-�,�8(T( PROJECT CONTACT i TELEPHONE Y 33 <br /> F FACILITY NAME P I � T PHONE /'Zc�, <br /> A <br /> C ADDRESS <br /> I tZO J ( c�C •C� <br /> L CROSS STREET 4= lam— <br /> I <br /> T OWN PERAf .� PHONE / <br /> YI 8fc " z� i tLccic 2 47-5;W -C,17 2 <br /> C CONTRACTOR NAME -KT _ _ J �_�i L ,� . PHONE M Z Z TSi�3� <br /> 0 <br /> N CONTRACTOR ADDRESS'6•�, - ` V- �-C `� � G LIC Y 7�i: CLASS <br /> T J C t <br /> R INSURER — �4 4qrn �- L C, WORK.COMP. `, ( 2- <br /> A <br /> C FIRE DISTRICT <-' — PERMIT k <br /> T C c —n r� <br /> 0 LABORATORY NAMC >` ; PHONE <br /> R <br /> SAMPLING FIRM PHONE M <br /> T <br /> TANNKK IDM TANK SIE CHEMfE,yLS STORED CURRENTLY/PRFYI OUSLY DATE UST INSTALLED <br /> 39- 6 6- i - LiJ l )f i•sc.� rg�6 <br /> T 39- <br /> A 39- =(l <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROYED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A 'SEF' IMEMT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME "fol- -�TT�T77TYT�T'�-.DATE <br /> ��������������������IIIslIl71111111I1 L11�� 11711f 11111111111111111����� ITITM <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH T71f PERMIT-.IS ISSUED, 1 SMALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS,WFJ IFORMIA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I <br /> "I CERTIFY THAT IN THE PE FORMANCE OF( E TSARK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF GL ORNIA.• 1 <br /> APPLICANT'S SIGNATURE: - TITLE <br /> I <br /> ' <br /> EH 23 046 (Revised 7/10/92) Page 3 ' <br />