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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 -i;e CLOSURE IN PLACE <br /> EPA SITE NC o6 PROJECT CONTACT i TELEPHONE N 481- qoW ab)I <br /> F FACILITY NAME h C Dl PHONE N a6q-qd9-%75 <br /> A n� /) - <br /> C ADDRESS <br /> 1 _ <br /> L CROSS STREET Qn <br /> 1 - <br /> T OWNER/OPERATOR Sim <br /> PH�,E& <br /> n g- 9�a-5&7s <br /> Y �f T l <br /> C CONTRACTOR NAME Q. r iyi ZYl�: . (-(l(A 1Ve I¢¢ PHONE N OA-5 - '� <br /> N CONTRACTOR ADDRESS ..RLQ 6t n O/'1 G LIC N (YOUW/7LI CLASS <br /> R INSURERErt <br /> C FIRE DISTRICT Qn Smad PERNIT N <br /> T PNONE N0 LASOUITONY NAME Syn/ �j ��yy p// // �/ <br /> R PHONE N LIN- 077- /� <br /> SAMPLING FIRM <br /> IIIIIIIIIITINK III�I III" III 8 ARK SIZE CH41KJCALS ST iRED CURAEITLY/,REVI ' SLY DATE ST INSTALLED <br /> TANK ID I✓� 111h .1/1 <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- r <br /> IIII <br /> P <br /> L APPROVED � APPROVED WITH CONDITION(S) __ DISAPPROVED <br /> A 1 (S ACHMENT WITH CONDITIONS) DATE 1$ <br /> N PLAN REVIEWERS NAME IIIIIIIFFFTumIIII"IIIII <br /> IIIIIIIIIIIIIIIIIIII <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN RCOUNTY <br /> THELIEFHEMISCA SSIGNATURE <br /> CERTIFIES <br /> THE <br /> iCERTIFY <br /> THAT IN <br /> THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT IS ISUEEDD, ISMALLHOT EMPLOY ANY PERSON IN SUCH A KANNERAS TO BECOME <br /> "I <br /> SUBJECT TO <br /> THATEIN TNHENPEERFA7ION 0RMANCEAWS OF OF THE WORKOWFORAWHICHOTHISCPRMITW ISNG OR ISSUED ICSHALLCTING EMPLOYIGNATURE PERSONS SUBJECTETOTWWORKER'a(NG: <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: Q TITLE (f <br /> Fl) - DATE <br /> '),", .mel, cot, <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />