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1_2 h <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />ANCE <br />TANK <br />APTHISAPERMITFOR <br />EXPIRES RN90TDAYSP FROM THEOAPPROVRE VAALADATE. DOT NOT WRITE OF PLACE OIN ANYSHADEDUNDERGROUND <br />AREAS. INDICATE PERMIT TYPESTORAGE <br />BELOW: <br />AREMOVAL __ TEMPORARY CLOSURE __ CLOSURE IN PLACE <br />iz7 <br />EH 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE #CA C. 060 U' 412 PROJECT CONTACT d 1hLtVtf et . John Y1G - J V 7J O <br />F <br />PHONE # - 8 6 — Z87 <br />FACILITY NAME <br />CAGEY <br />A <br />C <br />T+ <br />ADDRESS 6 4 <br />L <br />CROSS STREET ^f <br />PHONE # <br />T <br />Y <br />OWNER/OPERATOR O <br />'r Ti2i4� A PAUL V" A 0- g - <br />C <br />I _ <br />CONTRACTOR NAME r PHONE 09 <br />O <br />N <br />CA LIC # �5/$ CLASS t <br />CONTRACTOR ADDRESSgra - A • TQ �, <br />R <br />TAli <br />INSURER .O /O /v % oM <br />IJORK.COMP.# <br />A <br />PERMIT # <br />C <br />FIRE DISTRICT <br />T <br />0 <br />_ <br />LABORATORY NAME C k y En/Uu-on1MENr -5AW6 EcHn1o[ <br />PHONE # <br />/ - PY6 3/8! A 36 / <br />R <br />SAMPLING FIRM Vj/C,91UH WLA L- PHONE # <br />pp��//����{{�� <br />Iilllillllllllll�(illfllllll CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANK ID # TANK S on/Cn9cJn� <br />/A Se iNr <br />3- - <br />9 <br />d.T!M- <br />A <br />39- / Z. y l: U <br />N <br />39- <br />K <br />39- <br />39- <br />��TT�YT�-�Y�7��7E��F�77-E� <br />39• T fIII1111111t111IU1111l <br />IIII <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />HMENT 7 <br />A (SEEVI7M CONDITIONS) DATE /� <br />`C DATE <br />SII <br />N PLAN REVIEWERS NAME <br />IIIIIIIIIIIIIIIIIIII <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH -SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER <br />PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />THE <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />e1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />COMPENSATIDN LAWS OF CALIFORNIA." <br />TITLE T'2�5-TEEN/ DATE 0 Z <br />APPLICANT'S SIGNATURE: <br />EH 23 046 (Revised 7/10/92) Page 3 <br />