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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABAMDONKENT 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 />r REMOVAL TEMPORARY CLOSURE CLOSURE IN PUCE <br />.L.- <br />EN 23 04;4 a edA;w) 741,S/ .S cTi�l Page 3 V <br />C3Jspq,nPX1 nc pzzz! , /�'oe�Tac�olet 7'7'42� <br />�� <br />EPA SITE # C pte IPROJECT <br />CONTACT & TELEPHONE # <br />F <br />FACILITY NAM <br />PHONE <br />A <br />I <br />C <br />I <br />ADDRESS <br />L <br />I <br />CROSS STREET <br />T <br />Y <br />OWNER/OPERATOR <br />PHONE # <br />-!3s_ <br />C <br />0 <br />CONTRACTOR NAME <br />PHONE # <br />N <br />T <br />CONTRACTOR ADDRESS �CUC Lt/CSf _ Y7 lacc <br />G LIC # �g� <br />CLASS N/I�z —. <br />R <br />A <br />INSURER V A� �' <br />WORK. COMP.#Ge&IC- ✓49 IID cc <br />✓ �KIJJ <br />C <br />FIRE DISTRICT I', <br />PERMIT # <br />T <br />0 <br />R <br />LABORATORY NAMErw',-- �4 <br />PNONE # 26`i S 7 6, <br />_, C' 0 <br />SAMPLING FIRM Q PHONE # i <br />ilillllllllllllllllllilllillll <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39 - <br />T <br />39 - OCD -ni <br />�—� <br />A <br />39- • CIL <br />/.( cl ✓L <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P ILII �j <br />L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A SEE ATTACHMENT WITH CONDITIONS) _ l <br />N PLAN REVIEWERS MAKE (p <br />DATE <br />11111111111111111111 I I I I I <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCADUIN 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, I SMALL 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 WNIC THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />/J p <br />APPLICANT'S SIGNATURE: \ TITLE <br />(-L�'�-IV� DATE <br />.L.- <br />EN 23 04;4 a edA;w) 741,S/ .S cTi�l Page 3 V <br />C3Jspq,nPX1 nc pzzz! , /�'oe�Tac�olet 7'7'42� <br />�� <br />