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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 FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />Y6-ko41; ;4 REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />Q <br />EPA SITE #'CA0005q?Mtf <br />PROJECT CONTACT d TELEPHONE # <br />F <br />FACILITY NAME.�.r. _ <br />PHONE #Ct 37 93 <br />A <br />C <br />I' <br />ADDRESS1 :7 14 <br />1 <br />L <br />CROSS STREET <br />I <br />Y <br />ONNER/OPERATOQ, IT ITI O F STO ``'TON <br />•] <br />PHONE <br />as q 937 $$a? <br />C <br />CONTRACTOR NAME hR EST ( ` T E CkR 1 Pc <br />1 <br />PHONE #C)61b gooc <br />0 <br />N <br />CONTRACTOR ADDRESS a OX '� % T% RESNa <br />CA LIC # <br />3Sg <br />CLASS MAZ-C57-Q,I <br />R <br />•� <br />INSURER W C STE R f� TR a.G.i Cx <br />WORK. COMP.# STATS F4NIj <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T_ <br />0 <br />LABORATORY NAME ' 6 �` 1 %C - <br />PHONE #7/ 77/ 6 90 0 <br />! <br />SAMPLING FIRM 5efvws, PAl 3-1—q <br />PHONE # <br />����� ��I <br />N ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE U T INSTALLED <br />39- 2 O 1 <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />uii r <br />mrrrmrRmmtrr <br />P <br />L <br />APPROVED APPROVED WITH CONDITION(S) <br />_ DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />WTi1umffTT <br />'�I'�I�������'�II"' ►I}AT1� <br />DATE <br />it 111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />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 <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 />SUBJECT <br />TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"1 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />TITLE <br />DATE i' 7 <br />APPLICANT'S <br />SIGNATURE: <br />EH 23 046 (Revised 7/10/92) Page 3 <br />Q <br />