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law <br /> 40*4000 <br /> 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 # V PROJECT CONTACT & TELEPHONE # T" o,/ <br /> F FACILITY NAME L& I ( I <br /> C ADDRESS �ry,w q Fl PHONE # apLt _ 15 <br /> A <br /> - �) <br /> I <br /> L CROSS STREET <br /> I <br /> YOLMER/OPERATORi / � f-t PHONE # <br /> C CONTRACTOR NAME G� PHONE # <br /> 0 ' <br /> N CONTRACTOR ADDRESS f �..uC G LIC # CLASS <br /> T <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAME �<- .e�� PHONE # <br /> R <br /> SAMPLING FIRM PHONE # <br /> TANK ID # _ TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- —— <br /> T 39- — Uo <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> III (TTlffiffffffffffm <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A --ma�yy EE ATTACHMENT V[TN CONDITIONS) p . <br /> N PLAN REVIEWERS NAME L�'L�itiLa7� G �'(e. DATE — .3 -�--• <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 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 L#S OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE F THE ORK FOR YHI �R'THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." .j <br /> APPLICANT'S SIGNATURE: Z,� TITLE /�'- '/"� DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />