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.r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARYZCOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FR HE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # Q Q PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME �.S PHONE <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR �� PHONE <br /> Y <br /> C CONTRACTOR NAME '� O PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS ' _A '" n CA LIC # Z��S CLASS <br /> T <br /> R INSURER NO�Si'QAKL �e.IbElJI►,)i WORK.COMP.# <br /> A 0-0616532- <br /> C FIRE DISTRICT PERMIT # <br /> T ✓V /7;E(!n,- <br /> 0 <br /> 0 LABORATORY NAME ( NLOyIL 1 PHONE #(2,0j) �'Srl -'7$36 <br /> R ,K <br /> SAMPLING FIRM PHONE # <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39• D—G r-iYSo �.�/P 19 7 7 <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 1111111111111111111111111 11111111111111111111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SE ATWCHMENT WITH CONDITIONS) <br /> 4-7 <br /> N PLAN REVIEWERS NAME DATE _ <br /> — 111111111111111 <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 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 0 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 / AAAd TITLE DATE "�' _�./�[ `)✓ <br /> EH 23 04(6\1 (Revised 7/10/92) / " - Page 3 V <br />