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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> CE <br /> TANK <br /> APPLICATION <br /> THIS PERMIT EXPIRES 90DAYSFROM THE APPROVAL ROVAL DAE OR TE. DOTIN NOT WRIT °N AANYESGROUND HADED AREAS. INDICATE <br /> NDICASETPERMITTTTYPEEBELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # � jj��2� PROJECT CONTACT i TELEPHONE # 00 , 7G f_ p <br /> F FACILITY NAME PHONE <br /> r�C2��.,J ��- � auF <br /> Ar4 Sam <br /> C ADDRESS -TIS1 ��k��;� �U��1, �'�c,�rZ`�J <br /> iI <br /> L CROSS STREET <br /> I PHONE # . <br /> T OWNER/OPERATOR <br /> Y DDA)l �I 4 <br /> ' CONTRACTOR NAME -]3,q4.— PHONE # �C ,��r <br /> O LIC # �,+ CLASS <br /> H CONTRACTOR ADDRESS �p [ r,0,`9 i AJ�r �'fSC7� SSS p '� <br /> ' T WORK.COMP.# &L:p�CX/�`�SS'S <br /> R INSURERj/cr�rj Am e /i- <br /> A PERMIT # <br /> C IRE DISTRICT ,� <br /> 7 <br /> 0 LABORATORY KAME PHONE # � - 66 '7- .�—d Sr� <br /> R ,�y� n, . PHONE # <br /> LF �fC?2� c2oj44f, �'"9 <br /> LING FIRM G <br /> ' <br /> TANK, t[[IE�RI�l11i� TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- �ANKy ID <br /> T 39- <br /> A 39- <br /> ' N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L PR VED APPR I CONDITIONS) DISAPPROVED <br /> A TH CONDITIONS) <br /> N PLAN REVIEWERS 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, 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 FOLLOWING: <br /> ' <br /> 161 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 CALIFORN A." <br /> APPLICANT'S SIGNATURE: h / TITLE tL1+Vi cf1C �/� DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br /> 1 <br />