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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 /> X, REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # C def ©Zfl ^4"Yj PROJECT CONTACT 8 TELEPHONE #--TQli�xo -88-Z9 <br /> F FACILITY NAME •1 pD(� T© -I-f� °0 PHONE # <br /> A <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> PHONE # <br /> T OWNER/OPERATOR <br /> Y <br /> C CONTRACTOR NAME (Ylf+;$Q,SS1G C N0,E7 • `S PHONE #l�l _ 00 <br /> 0 CA LIC # 2 CLASS HR _ I <br /> N CONTRACTOR ADDRESS <br /> T WORK.COMP.# <br /> R INSURER 'S' (LN T lA <br /> A r PERMIT # <br /> C FIRE DISTRICT <br /> T <br /> 0 LABORATORY NAME A PHONE #('1114) I^ 69 Cb <br /> R SAMPLING FIRMGE0 H%-k9IT S>~9-0(G%,S �� PHONE # Qv 95b- <br /> f1111IIIIIIIIIIIIII������ <br /> TANK ID # TANK BAIZE CREMLCALS STORED,..VJRRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- (s o3-c9R DI cFl, ia£1 191 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- T <br /> ffumTtffffmffmTffffmffgffw <br /> P <br /> APPROVED APV1RO1V"ED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE A ITHCONDITIONS)) DATE <br /> PLAN REVIEWERS NAME � <br /> 2 <br /> IIIIIIIII III III IITTII1111iRirTi11Ti1 ,,' �11111yIllI <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 1S ISSUED, 1 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANT'S SIGNATURE: TITLE �7?�510£(�31' DATE -31 <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />