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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 0C,4 C7SI Sq 2 Z,11 Z PROJECT CONTACT B TELEPHONE N jAk <br /> F FACILITY N C'i-Smfc� FeOn���JA - Coil PHONE f <br /> A <br /> C ADDRESS 4 t-aK of U V //7/t,j i <br /> I J <br /> L CROSS STREET <br /> 1 <br /> �j `' C /� PIIONE <br /> Y fRCl\1 A / CGS C c� 1 ( oils /1 � <br /> C CONTRACTOR NAME - - n, ) -i- PHONE f 3J, <br /> 0 l <br /> N CONTRACTOR ADDRESSjylf2 _ 1 �- CA LIC f Q CLASS _ NRZ <br /> T q WORK.CO1P-01,Z1 (� <br /> R INSURER o /� 1 C <br /> A PERMIT f <br /> C FIRE DISTRICT <br /> T <br /> O LABORATORY NAME PHONE f <br /> R SAMPLING FIRM (:U;A /n - t PHONE fes`-- 6 X75=9'3S� <br /> nnnnnnnnn���un i n <br /> TANK ID SAOSIZE CHEMICALS STORED OR�RENTLY/PREVIOUSLY DA7Wj INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39, <br /> I I I I I I I I I I I I I I I I I I I I I I I I I <br /> P ► <br /> L APPROVED X APPROVED WITH COWDITION(S) _ DISAPPROVED <br /> N PIAN REVIEWERS HANEFF��EEEE iT ISEE ATTACHMENT <br /> WITH CONDITIONS) + V <br /> r <br /> A DATE <br /> 111111'1111111111111nuffmYYYiff7111'I <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 19 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS 70 BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINGS <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FON WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.• <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> appk&wd w-i fk) 467xt r a d��'�, <br /> Test � .eea cea � -t-a'a'o, wsta�LQee� <br /> EN 23 046 (Revised 7/10/92) Page 3 <br />