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ENVIRONMENTAL HEALTH DIVISION s <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE!IPERMIT ' <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> TT i <br /> EPA SITE # ©� $�/ PROJECT CONTACT & TELEPHONE <br /> F FACILITY NAME PHONE # .� <br /> A ! <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR 3 PHONE # <br /> do <br /> JM <br /> C CONTRACTOR NAME ��„ ^f �� PHONE # D L/ f <br /> O sti 7 <br /> N CONTRACTOR ADDRESS CA LIC #} //i1b / CLASS.�� <br /> T Lr L� <br /> R INSURER WORK.CONIP.#Alt-I //o-:"196 <br /> A <br /> C FIRE DISTRICT Is <br /> 1 PERMIT # <br /> T <br /> 0 LABORATORY NAME ting!- 'F+ Com{.. 4 ? PHONE <br /> Ge0 �-e , L6, i �9® <br /> R <br /> SAMPLING FIRM T S , r)e1, l w►+e.Yt 'c4L PHONE 1 <br /> 1[I11111IIIIIIIIlI1llI11111lII <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 0.57-2/ -! y Oo C, on -za 4= Id/v!o&) <br /> T 39' 5-21 "� 5/0,0 0G ,:� VI t c. <br /> A 39- s 7/ �3 00 0'41 <br /> N 39% aS7/ - -�V a 00 <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> 9-39- <br /> 39-P <br /> L /APPROVED APPROVED WITH CONDITION(S) -;DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME Ip DATE <br /> 1I11111111Hill 1111111111111IIllIl11lII11111111111111111111111 !1 lllll111!11lllfllllll11111111111111111111111111111111111 <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 SIGNATUREICERTIFiES THE FOLLOWINGf_ "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,�II SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> F, <br /> APPLICANT'S SIGNATURE: �jil� _ _1�fA _ __ _ TITLE LIJP'!/1 ��DATE <br /> I� <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />