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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 />/ <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE # 6,02-7—D QQA/036 <br />CONTACT 8 TELEPHONE if <br />R! ��� nlr a C17i U <br />F <br />FACILITY NAME <br />PHONE # <br />A <br />L A&57Z�l <br />C <br />I <br />ADDRESS <br />L <br />��j <br />CROSS STREET YV"59T L�✓� <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />i <br />/1) 9 y/y <br />C <br />0 <br />CONTRACTOR NAME �SOoJ ��6/� <br />PHONE # 140 G3 <br />N <br />CONTRACTOR ADDRESSaC/'� {�dN <br />CA LIC <br />CLASS14 <br />T <br />�v <br />R <br />INSURER' a�gJ2�,�,`� <br />WORK.COMP.# (,IG <br />A <br />/ S <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />R <br />LABORATORY NAME�G C L L �./ ` <br />PHONE # S/d '7q p le -?'o <br />/ / <br />SAMPLING FIRM O--C-A ?, $ NC •(j�f-,S <br />1111111111 11 11111111111 <br />PHONE #S�Q 37� <br />TANK 1 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39 - <br />T <br />39- <br />''-Tu <br />A <br />39- <br />�i <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />1111 I II I I I II 111 I I <br />I I I I Ii1TTTnummin <br />L <br />_ APPROVED APPROVED WITH CONDITIONS) <br />DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I <br />DATE <br />I I I I I I ffm III II <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />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 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />/� A <br />APPLICANT'S <br />SIGNATURE: ./f ir` r i TIT <br />DATE <br />WE <br />/ <br />EH 23 046 (Revised 4/26/94) Page 3 <br />