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• u J <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 /> REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # C loll69 688 PROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAME DURANGo T/RF Co/61P,9NY PHONE # 9y3'v9?F-7 <br /> A 7 1 c �7^/J <br /> C ADDRESS ZF//9 S GL 1",o JDA i 7' <br /> I <br /> L CROSS STREET LO!-YELLfI!/Ei1�U� <br /> I <br /> T OWNER/OPERATOR PRONE # <br /> Y <br /> C CONTRACTOR NAME vi WNE S/1.�1� PHONE <br /> N CONTRACTOR ADDRESS z� '>�T Ave/�vP ..5�{� IC # 1 CLASS <br /> CA L <br /> R INSURER L2a eco a WJY3 WORK.COMP.# ��11 <br /> C FIRE DISTRICT �7a�70h PERMIT # 7-2,6"0 <br /> 0 LABORATORY NAME �i�'o 'L//1✓/�/AAY CWNTY�'� PHONE #s/Q�y3Q-��90 <br /> R SAMPLING FIRM N V'ezgv T ' As'J�' # <br /> unnuununw�n�umi PRONEs7�-9y>z/Os-i <br /> TANK 1D # TANK SIZ CH ICALS STORED WWPMTtY/PREVIOUSLY DATE UST INSTALLED <br /> 39-7A2s6y0/ 1Q' vo� c AL,lav :P,�L �9�y i974r <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L _ APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAKE �-Z4ji4dQa4 DATE 3 <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 CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A KANNER 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: !?P�n /i/�i�N/L� l '7 TITLE �i•"�rr6� DATE <br /> CONDITION(S): <br /> � P�rouic{Q g� l{r�r � Viand � ppm- Ph' <br /> I Me USf w/slurry. <br /> Z//1 Pro u)& P6cfooL�� r-Lo5f lcfic„ <br /> EH Z3 046 (Revised 7/I /96 Page 3 <br />