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C�A z Vl6s <br /> .. � <br /> ENVIRONMENTAL HEALTH DIVISION te SPX <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> v REMOVAL TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE #CA/'1c/ V <br /> . O^O �U/� (r� PROJECT CONTACT 8 TELEPHONE # ANSrEt/EvsEYU Q�� ��✓`� <br /> F FACILITY NAME � N TT F�,Qr/(.� 2 PHONE # <br /> A <br /> C ADDRESS ®�q gWP6oa�ur S'za.WrZov <br /> 1 <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y I Jiptl TYzol� &;? <br /> C CONTRACTOR NAME SCO PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS (F? �1. 1 �dZ �J„ CA LIC # (=!(�y�6 (� CLASS <br /> T / '/ <br /> R INSURER rTn,fj!> (C-1WORK.COMP.# &J�gQ�f,L/ <br /> A � r <br /> C FIRE DISTRICT g(Z/ Q� ST�KTo� PERMIT # <br /> T / <br /> 0 LABORATORY NAME �eD 9N�Lyr/Ld` PHONE # '�j cf 53.Z eyoo <br /> R '( <br /> SAMPLING FIRM EI�CQ �/vf}L (�'9 C_ PHONE # 2101 5?Z �p0 <br /> III II III II III II II III it 111 li 111 <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- ,7 /� <br /> 3 39- �dD—D� rp O V.V 15P� S <br /> A 39- 00 0 S <br /> N 39- O /d Dp JJYCSEL <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIIIIIIIIIIIIIIIIIIIIIIIIII III11111111111111111111111111111 IIIIIIIIII11111111111111111111111111111 IIIliilllllllllllllll <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME (NZ�C.�'./u—(SEEIITTAC NT WITH COyp IT IONS) DATE <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIilllllllllllllllllll <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JO40UIN 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: ��iV"N/fes TITLE (i DATE <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />