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a <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> 1C REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE r <br /> EPA SITE # i_.' (1-0 0t �p 12L1 PROJECT CONTACT & TELEPHONE # i�ltL� ). �G��-`-d� 1&? <br /> F FACILITY NAMEPHONE # <br /> C(a�de C , lt.cve Lv�ts<r���a� C� S�Ie Pir�Ihcl_,z <br /> A <br /> CADDRESS <br /> I (,F-::7 �Fu5i <br /> L CROSS STREET l � <br /> 1 NOC�Ln eG�vN�� ��o�C <br /> T OWNER/OPERATOR �� �^ `� �«._ L�� PHONE # <br /> Y C �c <br /> C CONTRACTOR NAME (� S I� Lam{^ ` �- PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS �v �j,�� �,�� ��^ �'- �(SZ CA LIC -?—c1 -tf3 CLASS <br /> T <br /> R INSURER �(LvU f C1 WORK.COMP.#V�C�- <br /> C FIRE DISTRICT ^ PERMIT # <br /> T <br /> 0 LABORATORY NAME �(y�et ,, N y,�k\ PHONE # to`L(Z�v_ Gb•(� <br /> R <br /> SAMPLING FIRM L "`y \cfl (���-J C2.'v PHONE # <br /> III <br /> Jill <br /> IIII <br /> 11111111111111111 <br /> TAN ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 4C75 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> Iillllllllllllllll 1111111111 IIIII 11111 i II I I I I 111 1111111 <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A T�� EE ATTACHMENT WITH CONDITIONS) 9 a <br /> N PLAN REVIEWERS NAME DATE D�N <br /> 11111111111111111111 111111 <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 PERFOR ANCE OF T7ORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI FOR <br /> IA." <br /> W.J.t0crOG,!ALD <br /> APPLICANT'S SIGNATURE: TITLE Assistant Socretry DATE _ <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />