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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 TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> f <br /> EPA SITE PROJECT CONTACT i TELEPHONEZt, <br /> F FACILITY NAME �—y PHONE Ize,er — <br /> A E <br /> C ADDRESS I~_ 3{ CTC V <br /> CAI <br /> L CROSS STREET <br /> I PHONE IN��A <br /> T OWNER/OPERATOR 'J � ,3� c <br /> Y <br /> C CONTRACTOR NAME�7 <br /> fC <br /> PHONE 0 ��� L� [0N CONTRACTOR ADDRESS' j� �. � 11�3„ A LIC aM 3C} �� -� CLASS i <br /> T r� > WORK.COMP.# �, E' C. <br /> R INSURER ;� C. J <br /> A PERMIT M <br /> C FIRE DISTRICT tn, t�'—�t ,� t{�l� Y <br /> T PHONE "/L• r <br /> 0 LABORATORY NAMCC-f�rUa T (% J �lE: tJ <br /> RPHONE N <br /> SAMPLING FIRM <br /> TANK S1 E CHEM C LS 5TORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID 9 -6 <br /> 39- 1 0(g <br /> T 39- <br /> A <br /> 9 A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 1111 <br /> 4iff-� <br /> A T <br /> P <br /> L � APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> ENT WITH <br /> CONDITIONS) <br /> - DATE <br /> N {PLAN REVIEWERS <br /> AM ` 1111 [111111111I���N� <br /> APPLICANT RUST PERFORM ALL WORK IN ACCORDANCE'WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> "I CERTIFY THAT IN <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br /> THE PERFORMANCE Of THE WORK FOR WHICH"-THIS PERMIT IS ISSUED, I $HALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'$ COMPENSATION LAWt,OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINGS <br /> "1 CERTIFY THAT,IN THE PERF�O_RMANCE OFT E WOR FOIL WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'$ <br /> COMPENSATION LAWS OF CALIFI�iN1A." <br /> APPLICANT'S SIGNATURE: <br /> TITLE DATE <br /> s <br /> i <br /> EH 23 066 (Revised 7/10/92) Page 3 ` <br /> 1 , <br />