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ENVIRCNMENTAL 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 /> X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLL-A--CE <br /> EPA SITE # -� �O +`(p 1.5/v� PROJECT CONTACT S TELEPHONE # <br /> F FACILITY NAME <br /> A <br /> ADDRESS /�L <br /> r CROSS STREET <br /> t <br /> OWNER/OPERATOR PHONE # <br /> y6g 3 3S{� <br /> C CONTRACTOR NAME T } 1 -' -PHONE # <br /> D <br /> CONTRACTOR ADDRESS �� CA LIC # CLASS _ 14 Z <br /> T INSURER WORK.COMP.# It O <br /> FIRE DISTRICT p PERMIT # <br /> 1 <br /> LABORATORY NAMEPHONE # <br /> RZ <br /> SAMPLING FIRM H I\ PHONE # <br /> TANK ID Al TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 25L-o 1 IniCGY� Drosr.I <br /> T 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39• TtF11111i-FI-F� <br /> 111 <br /> APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) / / <br /> PLAN REVIEVERS NAME �' —�C. DATE ZL y E <br /> 11111111111111111111 1111111 fill I in I 11111111111111 <br /> APPLICANT !RUST PERFORM ALL WORK 114 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 /> 1E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> JBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> —1 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 CALIFORNIA.- ��u� <br /> _IPLICANT'S SIGNATURE: TITLE t �rp7 DATE �jQLy/y(Q_ <br /> EN 23 046 (Revised 7/10/92) Page 3 <br />