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m <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <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 />xREMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />h,aQ, N 0 <br />-rhid Ywa rwl <br />m <br />_ �__M, <br />i <br />AR <br />2, A <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />US.�' q47 U151 <br />F <br />FACILITY NAME `� <br />PHONE # bLf <br />Db <br />JJ <br />A <br />C <br />ADDRESS 3 <br />s'fR-ct-T <br />L <br />1EA <br />CROSS STREET <br />W€gM <br />I <br />T <br />OWNER/OPERATORRaz. t ftSE� <br />PHONE <br />Y <br />(t �'G <br />C <br />CONTRACTOR NAME DEL T ( <br />PHONE # 8 1 7-75"1 <br />C,S <br />° <br />N <br />CONTRACTOR ADDRESS <br />166)0 a U V IE AVE, <br />CA LIC # <br />CLASS <br />b5 36b A <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />�V -y <br />FIRE DISTRICT 5TU <br />PERMIT # <br />�1'bK <br />T <br />0 <br />LABORATORY NAME 5�}JQSD <br />COUNTYPRONE <br /># bb S <br />R <br />��y�,�L <br />SAMPLING FIRM �jlG.�, ewn1C. 2i R PHONE #-kq Ig 6 b a <br />G <br />TANKI���11111������ <br />TANK ID # TANK SIZE CHEMICALS STORED CU RRENTLY11PREVIOI.LSLj' DAL US T LLED <br />39- �5D (YkC,� Ui`i�15Q1 <br />I�pAS'�G- d -e_ C N <br />T <br />39- <br />r 'O <br />LiN <br />F- <br />A <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />\/ <br />L <br />APPROVED APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />_ <br />( EE ONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />i <br />O e I U <br />PLAN REVIEWER'S NAME <br />DATE <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY <br />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 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CAL1FO NIA." <br />I��f`'+"'�/1"T�. DATE <br />APPLICANT'S <br />SIGNATURE: TITLE <br />�JLY <br />CONDITION(S): <br />h,aQ, N 0 <br />-rhid Ywa rwl <br />m <br />_ �__M, <br />i <br />AR <br />2, A <br />