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�.. Vow <br /> 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. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> -EPA SITE # PROJECT CONTACT & TELEPHONE # cuLt vc.( Q oq._ 31 . Lku6C- <br /> F FACILITY NAME - C Q0. �Y PHONE # 7 <br /> A Trc�c Plank <7 <br /> C ADDRESS 3'r 1oo 1 br- \j` - <br /> 1 1 <br /> L CROSS STREET 1n0-fG <br /> I <br /> T OWNC OPERATOR PHONE # <br /> DC CONTRACTOR NAME �. - -t PHONE # //��,./ p <br /> ' o-lS-F, <br /> N CONTRACTOR AODR'eSs C Cy"n-NQ (-(_IC'_ Y'a CA LIC # t, 1�-Z�, I CLASS A,-k72) <br /> R INSURER StaA P� lY WOR K.COMP.9 gCt -� <br /> A ^ <br /> C FIRE DISTRICT GT� i� �4' PERMIT # �4�✓e� <br /> T (� �/ <br /> 0 LABORATORY NAME Y( ; O.1 i- ..�_ o, f, COUNT PHONE # (+0-6_ q T� _ C <br /> R SAMPLING FIRM QMQ, Q+ �n���clrYLem - I PHONE # 9 <br /> IIIIIIIIIIIIIIIIIIIFPI1111 / <br /> TANK ID # TANK StZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> C—',0.LL.c <br /> T 39- <br /> 1 A 39- <br /> N 39- <br /> 1 K 39- <br /> 39- <br /> 39- <br /> Fp Iill I III I 111111 I I I 11 I II II 111 IIII11111 I IIIIII111111111111111111 IIIlillllllllilllllll <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> AS E f,QN0I :S BELOW AND/OR ON ATTACHMENT) <br /> WER'S NAME <br /> N ���\1ljfz <br /> PLAN REVIE _ DATE Q. 1E <br /> II11111II11111111IIIIIIIIIIIIIIII11111111111111111111IIIIIIIIIIIIIIIIIIIIIIIIII111IIIIIIIIIIIIIIIIIIII i!Illllilililllllllllll <br /> APPL:CANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JCAOUIN COUNTY PUBLIC HEALTH S'ERVIC'ES. OWNER OR LICENSED AG'ENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> ,HE 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." CONTRAC70R'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEESS THE FOLLOWING:1 <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, t SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI <br /> APPLICANT'S SIGNATURE: TITLE Dre,'3 � DATE <br /> CONDITION(S): <br /> E3 23 346 (Revised 9/11/96) Page 3 <br />