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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 /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # -�/�7-n �06,3�6_3�o � PROJECT CONTACT 8 TELEPHONE # O 1 <br /> F FACILITY NAME <br /> P �.FL NE-610 <br /> _ 1 1 PHONE # <br /> A <br /> C ADDRESS 3 96ortacm Cf Oc O <br /> L CROSS STREET <br /> T OWNER/OPERATOR PITC PHONE # <br /> Y o3 v 01 2-2�8$ <br /> C CONTRACTOR NAME ( •� PHONE # (� <br /> 0 <br /> N CONTRACTOR ADDRESS —v $jK SUI R6011A ?I CA LIC # 110070 CLASS <br /> T <br /> R INSURERertIr)n4' WORK.COMP.# WC <br /> A <br /> C FIRE DISTRICT Q PERMIT # 1 <br /> T <br /> 0 LABORATORY NAME I ( �� 4 DA PHONE # 5)a-53,57 <br /> R AA c <br /> SAMPLING FIRM T-TL orm ) L t1(C PHONE #e7%4) q —cool <br /> TANK, ID # TANK A S l CHEMICSIOµEt,CUgRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- "> I�t900—ue ) _ �l[1 iu�l 147.5 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> IIIII1111111111111 ��� I ff1T1T111TTfIT�fffff <br /> P �/ <br /> L ,-,p, APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) / <br /> N PLAN REVIEWERS NAME r71, DATE V <br /> fill fill III I I I I I I I I I ff1lTTffiflTTfR 11111 <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: 1-1 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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." C <br /> APPLICANT'S SIGNATURE: .�� fl TITLE DATE C <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />