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it <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR <br /> ENTCLOSURE <br /> ABANDONMENT IW PLACE <br /> QUNDERGROUND <br /> NTTSTORAGE <br /> TANK <br /> HISPEMITEXPIRS90DAYSOMTHE APPROALDATE. Do NOT WRITE IN ANYSADEDARES. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE M�• PRDJEGT CONTACT a TELEPIIONE 5m^1 , ZQ lw_esu <br /> PHONE i Y67 <br /> F FACIL1TY <br /> C ADDRESS[ <br /> I <br /> L CROSS STREET 6i>tic fit . <br /> 1 PIIQN �-c�7 <br /> T OWNER/OPERATOR 'fin \ 'S���457 <br /> Y �' O'T` .. 1 "r ` <br /> PHONE #209-110-St-13!; <br /> C CONTRACTOR NAME ' �t �0 <br /> k <br /> 0 Ch LIC Mj CLASSN CONTRACTOR ADDRESS ca <br /> T WORK.COMP.# <br /> R INSURER r <br /> A PERMIT 9 <br /> C FIRE DISTRICTGFry- k: <br /> T PHONE S,76 - Q <br /> 0 LABORATORY NAME <br /> R SAMPLING FIRK�� ` C'4� �li�`�C�}l�ICA[, S�rli�s PHON <br /> IIIIIIIIIIINKI1ipII�i�lli TANK SIE CHEMICALS TORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- �F a r /— <br /> T <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> IIII <br /> P IfITiT[[[T[lfillT1n11TT T <br /> L APPROVED APPROVED WITH COND1710i DISAPPROVED <br /> iSIE ATTAGH4ENT WITH LONDITIONS) <br /> A DATE <br /> N IIPLAN REVIEWERS NAME <br /> IIIIIIIIIIIIIIIIII I�T�I��I�iI1'1T11TITIT�i1Ti11IIIlI <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 WHIC <br /> THISAS"`SCONTRACTOR'SLNOT HIRING ORY ANY PERSON SUBCONTRACTIN0" SUCH A SIGNATUREACERTIFIES THENNER AS TO BECOME OLLOWING1 <br /> SUBJECT TO WORKER'S COMPENSATI <br /> "I CERTIFY THAT IN THE PERFOR YE WHICHIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> ICOMPENSATION LAWS OF <br /> TITL �s _ DATE <br /> APPLICANT'S SIGNATURE: <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />