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ENVIRONMENTAL HEALTH PIVDSION <br />APPLICATION FOR UNDERGROUND SYORA(E TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ASANOCMMENT IN PtAOE OF UMDERG.2CUND NAZARDOS SUBSTANCE STORAGE TANK <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO HOT %RITE IN ANY $HADED AREAS, INDICATE PERMIT TYPE GELOWi <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EB 23 O66 (Revised 6/26/44) Pape $ <br />EPA SITE tl� QDIIIIO 3�0j <br />PROJECT CONTACT d TELEPHONE d /Tl, <br />r�TL p �Z ^2T/Q <br />P <br />FACILITY NAME 11,4eowl ce %� <br />PHONE d <br />C <br />ADGRESBI— <br />L <br />cRDss STREET <br />I <br />I <br />DWHER,`OP£RAYOR <br />OL 000 <br />' T <br />WAAI44 $ewd$ , <br />IV /0 <br />". C <br />` �1� <br />CONTRACTOR NAME E�, �I/,Q,e,C,¢-7i0 - <br />AHONE r JFSZ <br />N <br />CONTRACTOR ADDRESS IJTI� ✓GFS" CA LIC dI <br />1 CLASS A �f <br />T <br />'. R <br />— <br />INSURER /L{/,fl� <br />11ORK.COMP.3 t qp o <br />�J � J✓� `!� <br />C <br />FIRE DISTRICT�!�/'•/i�j <br />PERMIT 4 <br />0 <br />LmmTCRY NAME G'F�iQdMAG.4$ <br />/ <br />PRONE N S/i3 �- YOf p — 9l <br />R <br />. <br />SAMPLING RN �� <br />PHONE d <br />� VL�'L it.? <br />jfjl <br />IlrrtiUll�i�K1111111111111111 <br />TANK SI24 CHEMICALS STOW D CURRFMTLT/PREY7CUGLY 0 TE US INSYA D <br />q3Q�l -0 ( rdd 646 �✓�la e.e s!N uawn <br />T <br />3s <br />i <br />A <br />S9• <br />34- <br />— <br />IN <br />K <br />f f <br />39� <br />`liiinllrt <br />11 r l 1 1 1 <br />1 1 11r 1 111111E <br />1 u <br />APPROVED APPROVW VITH GUNDgC�T:ON(5) <br />DISAPPROVED/AT <br />11ML <br />A I EMTW� t .� 1 j <br />DATE �l `P <br />PLAN REVIEWERS NAME tirllrl <br />nrrurrrllnunrrrtirt <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAOUIN COUNTY PUBLIC SERIN SERVICES. OWNER OR 410EUSEEB AOEkT'S SIGNATURE CERTIFIES <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, D SHALL NOT EMPLOY ANY <br />THE FOLLOWING: At CERTIFY THAT IN <br />PERSON IN SUCH A MANNER AS TO GECCME <br />STIWJFCT TO W'ORKER'S COIIPEMSATICN LAMS OF CALIFORNIA." CONTRACTOR'S HIRING OR $WECONTTRACT�GOYSIGNATUREFOLLOWING-. <br />SONS CERTIFIES <br />"T CERTIFY THAI IN TNR PERFORMANCE OF THE WORK FOR 'WHICH THIS PERMIT IS 1$$()ED, 1 JW SOTHE <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICAMT'S SIGNATURE-' �• TITLE <br />DATE lY 6 <br />h .4nC <br />EB 23 O66 (Revised 6/26/44) Pape $ <br />