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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />OSURE OR ABANDONMENT OUNDERGROUND ASSUBSTANCE <br />TE <br />TANK <br />APPLICATION FOR <br />PERMANENT/TEMPORARY <br />RAYIN ANYSHADEDARE.INDICAEPERMITTTPEBELOW' <br />THIS EXPIR90OAYSPoOMTHE APPROVALDATE 00 NOT WRITE <br />/ TEMPORARY CLOSURE CLOSURE IN PLACE <br />V REMOVAL � -- <br />CONTACT TELEPHONE <br />rA 93� 9" .nPROJECT R - — — <br />EPA SITE # PHONE # <br />F FACILITY NAME <br />A <br />C ADDRESS Z <br />I <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR <br />Y VrV <br />VW <br />C <br />0 <br />N <br />T <br />R <br />A <br />C <br />T <br />0 <br />R <br />CONTRACTOR NAME <br />CONTRACTOR ADDRESS <br />INSURER Seg ru <br />FIRE DISTRICT S <br />LABORATORY NAME <br />111. <br />39 <br />T 39% <br />A 39- <br />m 39- <br />K 39 <br />39- <br />39 - <br />I.OJ,' I CA LID # <br />PHONE # lSH <br />PHONE # <br />CLASS A - <br />YORK.COMP.# �KG <br />PERMIT # <br />PHONE # 5-77 O96' <br />PHONE # i I <br />...Tl V/PREVIOUSLY DATE <br />INSTALLED <br />����1111Illllllllulu�.........• <br />P APPROVED � APPROVED WITH CONDITION(S) DISAPPROVED <br />L ( E ATTACHMENT WITH CONDITIONS) DATE <br />A 1111 <br />H PLAN REVIEWERS NAME <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS 0 <br />SAN <br />APPLICANT <br />IN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE JOAQUIPERFORNpCOU Of TUE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />NCE <br />U CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />COMPENSATION LAWS OF CALIFORNIA." (� <br />DATE <br />APPLICANT'S SIGNATURE: <br />L <br />A? d a; GrT -� w �o�e�r� <br />PH /� L r 1 0-2-,)T',' <br />Page 3 <br />EN 23 046 (Revised 4/26/94) <br />