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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICA E PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE LOSURE IN PLACE <br /> "EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> U2t � �G'- 31 • �tU �C' <br /> F FACILITY NAME - 'T. } P�(t.Yc� PHONE <br /> A f� <br /> C ADDRESS 3'\O� 1 bc-Ve_ - <br /> 1 <br /> L CROSS STREET �0-<-(✓ <br /> I <br /> TOWNE OPERATOR PHONE # <br /> � Y �� �rac� St2� � � � 31 - '2) <br /> C - <br /> CONTRACTOR NAME �. PHONE # <br /> O <br /> N CONTRACTOR ADDRESS c_LVVI nle 6c CA LIC # JOS 1��j I CLASS <br /> ' R INSURER St0.�� i'�lY `"� WORK.COMP.# <br /> A ^ <br /> C FIRE DISTRICT G�� T/14 FU PERMIT # We.;ae <br /> T <br /> 0 LABORATORY NAME c.;, i- .`ru c` �, C PHONE # �C)c`_ q J(C _ C <br /> R T <br /> SAMPLING FIRM RQo-n-t ., 'p, �rlQ-'fc'(lm PHONE # <br /> Iillllllillillil71111hf11l1 I <br /> TANK ID # TANK SI CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 39- <br /> N 39- <br /> ( 39- <br /> 39- <br /> I p <br /> Iill it II I I I it i t IIIIIIIiIiI i1I1111111111111111111111II1111111111111111111111111111111111111111111111fII <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> AITIONS BELOW AND/OR ON ATTACHMENT) <br /> N �/'�JE" OND <br /> PLAN REVIEWER'S NAME.z"0 DATE is- <br /> 1111111111111111111111111111111111111111111I111111111111111111111111111111111111111111111111111111111111111 11111111111111111 <br /> APDL:CANT 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 LICENS"ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 CAI:FORNI " <br /> I <br /> APPLICANT'S SIGNATURE: L.../ TITLE DATE 9•Z�'g� <br /> C ON'DMON(S): <br /> EH 23 046 (Revised 9/77/96) Page 3 <br />