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0 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> TANK <br /> APPLICATION <br /> FOR <br /> EESNTYOPABANDONMENT IN PLACE IUNDERGROUND <br /> INTSTORAGE <br /> E <br /> THIS PERMITXPIR90DAYS FROM THE APROVALDATE. DONOT WRITE N ANYSHADED AREAS. INDICATE PERMIT TTYPEBELOW: <br /> REMOVAL <br /> _ TEMPORARY CLOSURE CLOSURE IN PLACE � 6}/I� <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # '/ <br /> / PHONE # � - y�3 Q <br /> F FACILITY NAME N [� <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I PHONE # 7 22 <br /> T OWNER/OPERATOR O, <br /> Y <br /> PHONE # "T6 <br /> C CONTRACTOR NAME C <br /> 0 CA LIC # �1 CLASS �- <br /> N CONTRACTOR ADDRESS 3 �Lr <br /> T � WORK.COMP.# <br /> R INSURER ' / /'L GAv'o-� <br /> A PERMIT # <br /> C FIRE DISTRICT <br /> T PHONE # <br /> O LABORATORY NAME <br /> R PHONE # <br /> SAMPLING FIRM <br /> ����111111111111111" TANK SIZE CHEMICALS FORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # �( az <br /> 39- li 60 - o I iQ 002 <br /> 2 <br /> T 39- ,, d .•� <br /> A 39- - <br /> N 39- „ vG <br /> K 39- <br /> 39- SRT <br /> 39• T 1'llt'1t1„"„1„"' <br /> lllifflnuTffflumll[fdffgnTnTiffunT <br /> P APPROVED APPROVED WITH CONDITION(S) _- DISAPPROVED <br /> L ( T T WITH CONDITIONS) <br /> A] �Yy DATE <br /> N PLAN REVIEWERS E <br /> NAMT�TTTiiTI1T111IIIII <br /> 111111111111111 NAK <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: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR VN)CN THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON 1N SUCH A MANNER AS TO BECOME <br /> SIBCERTIFYY THAT IN THENPERFORMANCEAWS OF THEGWORKOUFORAWHICHOUTHISCPEERRMITIS H IS ISSUED, I SHALLNG OR CEMPLOY SIGNATURE <br /> PERSONS SUBJECTCERTIFIES <br /> TOTWWORKER'�ING: <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> TITLE -r/V �OATE 6/- <br /> APPLICANT'S SIGNATURE: <br /> EH 23 046 (Revised 7/10/92) Page 3 <br /> JUN 0 3 1993 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />