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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 THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME 0100 L PHONE At dwsu—) <br /> A <br /> ADDRESS <br /> 1 303 f�rFrC AVE, <br /> I <br /> L CROSS STREET 101LLORi <br /> I <br /> Y OWNER/OPERATOR & .,5 ,( SSvC[�(�S� /.�C, PHONE # <br /> C CONTRACTOR NAME PHONE # <br /> 0 q <br /> N CONTRACTOR ADDRESS/.;2L/2 � s 444 eA7�27a CA LIC # �B'aGdl CLASS 4 hIN,Z B <br /> R INSURER LI $ T- ()� �J �� WORK.COMP.# <br /> A !39 OS 9� <br /> C FIRE DISTRICT PERMIT 4 <br /> T <br /> 0 LABORATORY NAME PHONE <br /> R <br /> SAMPLING FIRM I PHONE It <br /> TANK ID # TANK SIZE CHEMICALS STORED WRRENTLY/PREM WSLY DATE UST INSTALLED <br /> 39- /:Z,croa 64¢ --'J� UAi1�A-+7ED GJF3o ulJ f <br /> T 39- o-az� 6."+Ftt<h.75 WtE�Df.7 G,F-Sa c�,JE /4 90 <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <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 OFz <br /> FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN <br /> l _ / <br /> APPLICANT'S SIGNATURE: —7 II1�Ji`7G'x1 TITLE L���- itJ � DATE S � 7/;F <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />