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d <br />fl� �piR✓le /� �sv/ti> `/6� <br />1 DA oluif <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT 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 />AREMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE - <br />T <br />K 6�' t'. <br />pea <br />q" fo �nb a�-'�a� �fn�.n Seu� ref. <br />p� G t <br />s'6" p d''fo..• o/- .o^„( tF�ow. �yD e � f✓dl/nS Al ,�j �.,. '��olT !' i"•��4 <br />0% dJ" x 3� �;. f/ ': .._�) of ,.! r/Ie.�• Sc.J C�i- <br />EH 23 046 (Revised 7/10/92) Page 3 .. <br />JT i" )C Alr <br />EPA SITE # CAC 006 970 y2 <br />PROJECT CONTACT L TELEPHONE # O^n n '2 6 41- 3 -o-) <br />F <br />FACILITY NAMEC <br />PHONE # - 8.34 -z>'97 <br />AGE <br />A <br />C <br />_ <br />ADDRESS 6 L !r <br />L <br />CROSS STREET N k rH <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />T T,P.4L PWX VER/4/1 <br />2 0-931,- 0 <br />C <br />CONTRACTOR NAME Vjzz&Hr <br />PHONE # g _ 7 <br />0 <br />H <br />CONTRACTOR ADDRESS _ ,4, %Q G <br />CLASS y� <br />T <br />R <br />.�ww AA <br />INSURER Di'W /v % E OM <br />WORK.COMP.# Q <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />_ <br />LABORATORY NAME C k X11 v�CeI11MEN� SPae6- EL//A)OL <br />PHONE # . �y6 S/8l G 36 <br />R <br />- <br />�� l' a 'l <br />SAMPLING FIRM�p,��//�TT vsICDAJMr/✓TAL PHONE # OG-gj -O%S8 <br />_ ::�-TANK ID - -TANK SIZE CHEMI LS STORED WRRENTLY/PREVI WSLT DATE ST INSTALLED <br />w <br />39B <br />T <br />A <br />39 - - <br />39 <br />bASILL.VE _ <br />�A.S ff L/ LA/ AO �✓�1 <br />N <br />39- <br />K <br />39- <br />39- • <br />— <br />��❑ <br />P <br />L "[• APPROVED APPROVED WITH CONDITION(S) — DISAPPROVED <br />A CONDITIONS) 2- <br />- 2- <br />DATE (/ j� <br />N .`PLAN REVIEWERS NAME <br />_APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />''BAN JOAOU)N COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: e1 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.- <br />CC.�[[�nn�,, ``-- __ II _ <br />APPLICANT'S SIGNATURE: L-4 ._ TITLE Pz>;sraeN/ DATE 4*— <br />T <br />K 6�' t'. <br />pea <br />q" fo �nb a�-'�a� �fn�.n Seu� ref. <br />p� G t <br />s'6" p d''fo..• o/- .o^„( tF�ow. �yD e � f✓dl/nS Al ,�j �.,. '��olT !' i"•��4 <br />0% dJ" x 3� �;. f/ ': .._�) of ,.! r/Ie.�• Sc.J C�i- <br />EH 23 046 (Revised 7/10/92) Page 3 .. <br />JT i" )C Alr <br />