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(d 'JAN 1 3 19 93 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <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 TH APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW. <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> PROJECT CONTACT R TELEPHONE 0 <br /> EPA SITE #c AC Ot7 a ,6 <br /> F FACILITY NAME '� l C `� [ PHONE # Q —2 <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I PHONE # Z©9 <br /> TOWNER/OPERATOR <br /> Y ,� L i yg <br /> C CONTRACTOR NAME - C PHONE #, - <br /> 0 <br /> N CONTRACTOR ADDRESS g�� p CJI LiC # � ' U s CLASS Q <br /> R INSURER �. WOR K.COMP.#� O 6 <br /> A PERMIT # <br /> C FIRE DISTRICT rDAEOT <br /> LABORATORY NAME M CC� PHONE fZrl <br /> M1 SAMPLING FIRM Lot k PHONE # <br /> I l l l l l I!l l l l l l l l I l l l l Il l!l <br /> TANK ID # TANK SIZE CHEMICALS STORES WRRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> -- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> I I Ii1lTff1TT <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A fSEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS MA14E �'� c' " G� I!DATE <br /> IlllllllllilllllllllITIT1111 Hill <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 ERYICES: OIMER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: °I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK F ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'$ COMPENSATI LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINGS <br /> "I CERTIFY THAT IN THE PERF N E OF THE WORK FOR 1{HICK THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'$ <br /> COMPENSATION LAWS OF IF I _ <br /> APPLICANT'S SIGNATURE: TITL DATE <br /> EH 23 046 (Revised 7/10192) Page 3 <br />