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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE PPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE T T V� EPA SITE p C � 54 \ / 9 PROJECT CONTACT & TELEPHONE a �� y/T �BU liT TA' ,14— ,eeI L+ FACILITY NAME PHONE M�s6 b9 gO ADDRESS v / CROSS STREET J OWNER/OPERATOR F'u r' ( , L PHONE a v� rn �B�>»d JoNn Plcf 333 - �USb CPNTRACTOR 7 PHONE a�A CONTRACTOR ADDRESS Z6FX I LS� CA LIC a3�Ff ��' CLASS�� INSURERWORK.COMP.a -0 /� 7G FIRE.DISTRICT z" PERMIT a LABORATORY,NAME. PHONE a 4 1AMPLING:FIRMD6 Z4t- w"7< � PHONE a :2G TANK ID a TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY TE USI IN STALE 39- '> 'e' --- Oat z 39- 39- 39- — 39- 39- - 139- � MMUffMiii(iiTTiTTIiffMf L 'APPROVED A PROVED WITH CONDITION(S) DISAPPROVED L (SEE T ACHMENT WITH CONDITIONS) 4 PLAN REVIEWERS NAME Ei�/ DATE �r / ""II"I"'�'I'fl" IIIFFLIIIIIIIIIIRIIL�IIIIIIIIIIIIIIE�� APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTYPUBLIC.HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1-1 CERTIFY THAT IN THE PERFORMANCE OF.THE!WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S AIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE DATE Z3 046 (Revised 7/10/92) 1'OJtl 3 - 4 1994 JH