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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 FROI THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # C PROJECT CONTACT i TELEPHONE # �{/� �.E � &IzA� <br /> v tLJ l--•� 2a9-Szy i <br /> F FACILITY NAME PHONE # <br /> i A <br /> C ADDRESS <br /> J V <br /> - I CROSS STREET <br /> OWNER/OPERATOR l�1 \ V <br /> PHONE # <br /> Y <br /> OCONTRACTOR NAME T EL-T lseok LamI,1 11 54 O r'F PHONE # Z01 dI"t�- -7 <br /> N CONTRACTOR ADDRESS Avem g-.00,,,A l/ G LIC # (o'573/o to CLASS N`A � N <br /> AINSURER Sp O{{�daf _ LgRK.COMP.# /v <br /> C FIRE DISTRICT �L - �f \ <br /> Sa.�S_ I PERMIT # <br /> 0 LABORATORY NAME Sf+ERt/L�'jpD Ltc.. I <br /> RjypoPHONE 92Oi -(o(a7- 5255 <br /> SAMPLING FIRM Dot —T-e-C-I/l �CV E��wL�,( SKP�+/•f PHONE # i - D -� <br /> 111111111111111111111111111111 ' <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY REVI(X15 + I DATE USS INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> 4 39- <br /> K 39- <br /> 39- <br /> 39- <br /> E I I I I I I 1 l � i l l i�i113 I I I I I I I I I I I I <br /> APPROVED APPROVED WITH COND ITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 1 1 1 1 1 1 11111111111111 111111 <br /> APPLICANT MUST PERFORM ALL WORK IM ACCORDANCE WITH SAN JGOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 PE FORMANC: OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF <br /> CA <br /> RM <br /> COMPENSATION <br /> I <br /> i <br /> APPLICANT'S SIGNATURE: 1 TITLE V'35y"Zj"— DATE <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />