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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT Koji/ :2L4 / ' S - /a� <br />{ 2 <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 . 00 NOT WRITE IN ANY SHADED AREAS- INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> /T <br /> EPA SITE # C ' t�� / PROJECT CONTACT 8 TELEPHONE <br /> F FACILITY NAME Zy <br /> (' J G/ d �JT PHONE <br /> A v L F, / G LF/,l <br /> C ADDRESS A' 1 s / <br /> 1 620 <br /> L CROSS STREET1 / / / <br /> 1 Y �7 <br /> T OWNER/OPERATOR PHONE # h • K7'// �2 �G7 <br /> C CONTRACTOR NAME / j� T / PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS 9 ' CA LIC # CLASS / T <br /> R INSURER WORK. COMP . # 7a� Z ' <br /> C FIRE DISTRICT (� ✓ /� PERMIT # v <br /> T �f <br /> 0 LABORATORY NAME 1 ' �'� PHONE # <br /> R !/ O <br /> SAMPLING FIRM PHONE # <br /> IIIIIIIIIIIII1111IIIIIIIIIIIII <br /> TANK ID # TANKS 2E CNEM ALS STORED C RRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- ' D 0 U <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39 <br /> P III111111111111111111111111111IIilllllllllllllll�lllllllillllllllillllllllllllllllllllllllllillllllllllllilllllllillllllll <br /> L _ APPROVED APPROVED WITH CONDITION (S) _ DISAPPROVED <br />! A ( S�N��, A� TTA� CN�ME�NT /V�TH CONDITIONS) (� ��/•/ <br /> N PLAN REVIEWERS NAME L. . /� = DATE <br /> 1111111111III 1f1111111111111111111111111111111111111 ]III 11111 111111111111111111111111111111111111 ill 1111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS , AND RULES AND REGULATIONS OF <br /> SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES . OWNER OR LICENSED AGENT ' S SIGNATURE CERTIFIES THE FOLLOWING : 111 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 : G� TITLE Ir� DATE <br /> EH 23 046 (Rev 2/8/91 ) ft Page 3 <br />