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- / ��� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <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 CLOSURE IN PLACE <br /> / <br /> EPA SITE # C ) ' q`� / PROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAME 6PHONE # J� <br /> A /a LF� <br /> 1 C ADDRESS <br /> I N <br /> L [ROSS STREET <br /> 7 OWNER/OPERATOR PHONE # hme e <br /> C CONTRACTOR NAME 1 /-�, , / ,jam '� PHONE # <br /> w / -r <br /> N CONTRACTOR ADDRESS '*+ ( t% f CA LIC CLASS <br /> T `l` <br /> # "' ,Y A <br /> �� )` _ - l <br /> R INSURER Y2{ uC a ( VORK . COMP . # 7� <br /> A �l <br /> C FIRE DISTRICT ( V /� PERMIT # <br /> T <br /> 0 LABORATORY NAME ,L ' / PHONE # <br /> R (/ 6 <br /> SAMPLING FIRM PHONE # <br /> III II III II III II II III II III II III <br /> TANK ID # TANKS ZE CHEM ALS STORED C RRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39_ <br /> Loo <br /> o v <br /> T 39- <br /> A 39- <br /> N 39- Lay Y - <br /> K 39- <br /> '1 39 <br /> 39- <br /> L IIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIill <br /> IIIIIIIAPPIII111111110OND IT ION ( S ) DISAPPROVED <br /> 111111111111111111111111111111111111111111111111111111111111 <br /> A CONDITIONS ) <br /> N PLAN REVIEWERS NAME �i 1.,;,7 DATE <br /> IIIIIIiillllllllllllllllllllllllllllllllllllllllll11111111111111111111111111111111111111111111111111111111111111111111111111 <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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER ' S <br /> COMPENSATION LAWS OF CALIFORNIA . " / <br /> APPLICANT ' S SIGNATURE : L� I '�%� L�i- �.� 9 TITLEDATE * <br /> EH 23 046 ( Rev 2/8/91 ) ft Page 3 <br />