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0 � cry <br /> 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 THF APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> �//_/REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # ,. <br /> lo lo ut PROJECT CONTACT 8 TELEPHONE #M <br /> R FACILITY NAME 47 <br /> PHONE #20 <br /> ADDRESS <br /> L CROSS STREET p-0 <br /> 1 F - <br /> T OWNS OPERATOR <br /> Y PHONE # <br /> G- <br /> // z - ,Z- 6) <br /> CO CONTRACTOR NAME `;ZA � a LAY ,2 G -LIZr L.C?r PHONE #'j .-//�[ <br /> N CONTRACTOR ADDRESS CA LIC # <br /> T CLASS Lpqo-4w- <br /> INSURER WORK.COMP.# 8 6 <br /> C FIRE DISTRICT J ' PERMIT # <br /> LABORATORY NAME PHONE #>�G ,_l7/FJ,_ <br /> SAMPLING FIRM ��//{{[%(j , �G(}�, PHONE —7®C/ <br /> I11������� ew <br /> 39- <br /> TANK ID # TANK SIZE CHEMIC PR <br /> S STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> - _ u.-orL <br /> T 39- — — 5527fsJ'tL.Ll7 <br /> A 39- t'^ — <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 11111111111111111 I II11 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME C DATE ✓ 6/ <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAW .,OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFOR 0"HE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL <br /> 1 . <br /> APPLICANT'S SIGNATURE: —- TITLE <br /> �- <br /> �f' <br /> 'PH HD � r � � �o v,L,l f,'u� i )T wp-z- 2 <br /> EH 23 O46 (Revised 7/70/92) Page 3 <br />