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Now <br /> 1.0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> 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 # WL_ (5bOfl -71 Oq-LI PROJECT CONTACT & TELEPHONE # <br /> u ELr.') 1-29- 64-11V <br /> F FACILITY NAMEQ - -, �, PHONE #zo9 - --jZZ <br /> Q(� <br /> A q b � <br /> C ADDRESSZ13 i 'J S-r>7 LIQ•-•.ojj <br /> I 1� �+ <br /> L CROSS STREET FAfl..rv\ —D <br /> I <br /> T OWNER/OPERATOR 30101 A()01.1AA 4? It ZoO PHONE # <br /> Y LLs,4 A3 Ar7oLAAj wils 91-Ac) l 818- 86S-QZoo <br /> C CONTRACTOR NAME u&A <br /> M Co/ PHONE <br /> 0 # <br /> N CONTRACTOR ADDRESS 1'1 iX10 OJT-- T . CA LIC # Ow b CLASS <br /> T <br /> R INSURER WO K.COMP.# S <br /> A <br /> C FIRE DISTRICT ` PERMIT # <br /> 7 <br /> 0 LABORATORY NAMESELZjo COUNTY 4f)(j . PHONE #_71(1-3t119-93S <br /> R // uf�`� <br /> SAMPLING FIRM al. H. 14 . EN6 Cor • 89YS-C,T44AS JIB., 1 . PHONE # G6- 7-8-76/AS <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- /2000 �e.ta1 <br /> T 39- / ?-,0a o l <br /> A 39- <br /> N 39- 8oe• /�..,� <br /> K 39- <br /> 39- <br /> 39- <br /> IIIII I I 11111111111 X1111111 II111B11111 111111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( E CONDITIONS BELOW AND/OR ON ATTACHMENT) ) <br /> N PLAN REVIEWER'S NAME DATE / D ',� - <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 /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE I`D DATE <br /> CONDITION(S): O s���vL��nfl„ _ �� <br /> 77 <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />