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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. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAME - '-"C,(....0.0 f�`„ I PHONE <br /> A Y�wrcr <br /> C ADDRESS <br /> 1 3 coo <br /> 1� _ <br /> �J <br /> L CROSS STREET <br /> I <br /> T OWNE OPERATOR PHONE # <br /> Y ?, 3 l - <br /> C CONTRACTOR NAME _ PHONE # <br /> 0 :CB - <br /> N CONTRACTOR ADDRESS C CV"rnerc t& � CA LIC # S 1�! CLASS <br /> T / I� q <br /> R INSURER Ake WORK.COMP.# t(Ok4 1-+ <br /> A ^ <br /> C FIRE DISTRICT <br /> T FQ PERMIT # WGi liee <br /> 0 LABORATORY NAME04"�J- COUNT - CAO PHONE # c6_ a J _ <br /> R -TT'" � r <br /> SAMPLING FIRM j �.t\QJ lro � wne%v Q` �, Q-kces yy�,�,.. PHONE # a�� _C853-0-7s-8 <br /> TANK ID # TAnNK-Sf 2E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 1.�� l' L�OrN e se-I i91 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 111 111 1111111 11 <br /> L APPROVED APPROVED WITH CONDITIONCS) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <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: "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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI " - / p <br /> APPLICANT'S SIGNATURE: v` TITLE /SCJ l� 'LoW. DATE <br /> CONDITION(S): <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />