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ENVIRONMENTAL 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 /> REMOVAL TEMPORARY CLOSURE —_ CLOSURE IN PLACE <br /> EPA SITE 8 PROJECT CONTACT d TELEPHONE # $I- g6,7/9 <br /> F FACILITY NAME knie. Lin PHONE <br /> A <br /> C ADDRESS 031E r� Aye, Mbnf-eol� A- 9525-6(, <br /> I <br /> L CROSS STREET r <br /> fnxtiI <br /> T OWNER/OPERATOR PHONE Al <br /> Y <br /> C CONTRACTOR NAME - PHONE # 0W9- 9-a13/f� <br /> 0 n 2/ <br /> N CONTRACTOR ADDRESS `- YSP� CA LIC <br /> T <br /> R INSURER /� N� WORK.COMP.#�O� <br /> A <br /> C FIRE DISTRICT M - yDoG.�.. PERMIT # <br /> T <br /> 0 LABORATORY NAME PHONE # Affy- �a�c7-5a5� <br /> R <br /> SAMPLING FIRM � PHONE # �� <br /> 39- <br /> TANK <br /> - <br /> T [D # TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- 07 1 Zilef Un OWn <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> Ilil r <br /> P <br /> - L APPR VEDPPROVEO WITH CONDITION(S) DISAPPROVED (:ZA <br /> A TTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAM 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, 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 ------ <br /> .'I <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 /> i <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: - �""-"��l TITLE c F o DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />