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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAY 19 2000 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSUEFLNj{&OWEWAL HEALTH <br />PERMIT/SER',/ICES <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />V REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): , / + <br />0,41 <br />o x ate. C 'Lx� Ate) <br />aA aA.�, ha <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # ' G© 27, ��"� <br />PROJECT CONTACT & TELEPHONE # �- ��_ <br />F <br />FACILITY NAME <br />PHONE #Z() <br />A <br />C <br />ADDRESS 2S"_ 3 6 <br />e <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNE OPERATOR <br />PHONE # <br />Y <br />S - <br />gory-8SB-2' <br />C <br />CONTRACTOR NAME <br />Uf ��.r <br />PHONE <br />0 <br />N <br />CONTRACTOR ADDRESS 8 <br />�- <br />�`^ <br />CA LIC #W7 et -j6 <br />CLAS <br />O <br />/[44z�- <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME <br />- 6� COUNTY ; A <br />PHONE 11'5' j_ <br />R <br />SAMPLING FIRM <br />EO, F PHONE # lN7� 00,Fj <br />nununnui i Y ilio <br />TANK ID # <br />,W("mc'UTW-G, <br />TANK SIZ CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />aD G.4 <br />T <br />39- <br />A <br />39- <br />U O O <br />N <br />39- <br />K <br />39- <br />UT1A L- <br />39- <br />39- <br />— <br />111111111111111111111111111111 <br />P <br />L <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />( EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />t c <br />PLAN REVIEWER'S NAME <br />DATE J -� <br />APPLICANT MUST PERFORM ALL WORK <br />IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH <br />SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR <br />WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATI01 <br />LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN T ORN iF <br />OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OFFORT A. <br />I. <br />TITLE `«i-PTY"�7Ls�' �- DATE—�% <br />APPLICANT'S <br />SIGNATURE:•�Ef <br />CONDITION(S): , / + <br />0,41 <br />o x ate. C 'Lx� Ate) <br />aA aA.�, ha <br />EH 23 046 (Revised 9/11/96) Page 3 <br />