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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATICN FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> C44 0o00 3y/b REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN /PLACE 1 <br /> EPA SITE # 1G 6e 1ve^ PROJECT CONTACT L TELEPHONE # 5fe�rn _X1�Cl U/I 72-8 1GG <br /> 1 <br /> F FACILITY NAME �rc( f 6 PHONE # <br /> A v n <br /> ADDRESS <br /> I O ,j d Co IQ3 <br /> lJJ CC�� <br /> L CROSS STREET �UufefS <br /> 1 <br /> T OWNER/OPERATOR / PHONE # <br /> Y GronG oJr(Jc Lc a S3S <br /> C CONTRACTOR NAME r n on PHONE # <br /> 0 &C4 IA-ffrlh'I 111 bo CI <br /> N CONTRACTOR ADDRESS / 0 (' r may- CA LIC #- '57a j1 of D CLASS <br /> T Ej J C[1 _ Ood6'01I CL <br /> a o ��/n' WORK.NMP.# <br /> R INSURER CQ 110 f%1 t, h �,$U ICA>\(P <br /> A <br /> al <br /> C FIRE DISTRICT PERMIT #p 4p <br /> -I- <br /> 0 <br /> 0 LABORATORY NAME •r PHONE # <br /> old, f <br /> RSAMPLING FIRM ��>> }/ <br /> Iiliilllllllllllltlllllll�fll� r G��,l � OC• K�f) PHONE # / ? <br /> TANK ID # TANK SIZE CHEMICALS ST EDC RENTLY/PREM WSLY DATE UST INSTALLED <br /> 39- /493 <br /> T 39- /493 — ;z U& 4so11 <br /> A 39- <br /> N 39-:993 — <br /> K 39- i9n s L <br /> 39- <br /> 39- <br /> P illllllllllillililllllilllllll I111111111111111�11111111111111111111111111111111tlllllilillllllllfllllf {IIIIIIIIIIIIIIIillll <br /> L APPROVED ,�/ APPROVED WITH CONDITICNCS) DISAPPROVED <br /> AJ (S ATTR HMENT WITH CONDITIONS) t% 2 <br /> N PLAN REVIEWERS NAME DATE //Z'/A?;?— <br /> APPLICANT <br /> /A92APPLICANT 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 IS 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.- /- ^ <br /> APPLICANT'S SIGNATURE: - w TITLE 71 <br /> I <br /> EH 23 046 (Rev 2/8/97) ft Page 3 �, YY <br />