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lor14er O .,GZ ruesf /U' J—/tcp G4. <br /> ��6� l:reM .(Joctl o% A),Ik <br /> ` v Pao, crow 14ep ,r5-,-dew.1k, <br /> ENVIRONMENTAL HEALTH DIVISI <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABMUDOUMENT 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 CLOSURE IN PLACE <br /> EPA SITE N CqC 00090 PROJECT CONTACT d TELEPHONE a.JoHA) LyA)eH 2Oq- 833;0758 <br /> F FACILITY NAMEL T PHONE # 2,09- �.3,5_4700 <br /> A <br /> C ADDRESS Lj EVEMTH 5TREE 6 <br /> L CROSS STREET <br /> I DAM S TR E ET . <br /> T OWNER/OPERATOR PHONE a <br /> Y i H= r-FV TRAM ATrij MR PAUL VC-AMA. 6 -i-/NZ <br /> C CONTRACTOR NAME W -A1JIQ01 1-i"TA SiRutG -CAC PHONE # z01 - 83 -075 <br /> 0 <br /> N CONTRACTOR ADDRESS9 S Y R G LIC # GSSD CLASS /5NAZ NAT <br /> T n <br /> R INSURER Aj 6 N L L STA T - /tiI WORK.COMP.# <br /> A <br /> C FIRE DISTRICT TP—A c. PERMIT •# N A <br /> T ` <br /> 0 LABORATORY NAME C.K GN <br /> R S n1 WHIT R f GNN PHONE aSro— MI6 <br /> SAMPLING FIRM rN ZL15 Hr 1A PHONE # .2 - -07S <br /> TANK 1 a TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- -�(� �l`/(�ro��Bn FUEL Bt(.. C/NXA)(lQA/ <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APAPPROVED WITH COMDIT)ON(S) _ DISAPPROVED <br /> A (SEE ATTAC WITH CONDITIONS) <br /> PROVED <br /> N PLAN REVIEWERS NAME -�/ 4f, DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SMI J OUIN 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: "1 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.- p <br /> APPLICANT'S SIGNATURE: TITLE PiZES- Q M:AJ T' DATE /0 Z <br /> "'EH Z3 046 (Revised 7/10/92) i"\ Page 3 <br />