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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONII'IENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATES DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> -.f/REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # 'G L -O PROJECT CONTACT &. TELEPHONE # /ke- <br /> ZOq,S/G�1- Cyd <br /> f FACILITY NAME <br /> Lk <br /> A PHONE # ZQ�Wf7 �30� <br /> C ADDRESS / CLQ �O -: 4442 V,` /t„ a <br /> L CROSS STREET g_V,5 <br /> I <br /> T OWN /OPERATOR PHONE # <br /> Y ( <br /> C CONTRACTOR NAME , w U PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS Q 8 _ Ak o j - CA L I C #,3W 1�� CLASS G6 y� <br /> T <br /> R INSURER L pe..,-Z_ WORK.COMP. <br /> A <br /> TFIRE DISTRICT o� r PERMIT # <br /> RLABORATORY NAME C COUNTY PHONE #-5-/40 <br /> SAMPLING FIRM Vi> "EAfyl µmaul �/fG� PHONE <br /> ilillllillllllf 11111111111111 <br /> T ID # f TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- - / 1 O,o0oC. i."A <br /> T 39- - _i oFit4t — <br /> �". - <br /> A 39-' •. L_ pT t:��RML;,)�1 <br /> N 39- <br /> K 39- "j <br /> 39- <br /> NOV 1 77 MH <br /> till (iiTRtifiTi� <br /> P <br /> L _ APPROVE PROVED WITH CONDITIONS) DISAPPROVED PERMIT/SERVICES <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N � <br /> PLAN REVIEWER'S NAME DATE Z <br /> Illllilllillilll11111111111l11111111111111111111111111111111111111111111IIilllilllliilillllllillllllllllillliilitlllilll11111 <br /> APPLICANT MUST PERFORM ALL WORK I ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH ERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR ICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMP CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE ERFORMANC OF THE WORK'fOR.,W_HICN THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WORKER'S <br /> COMPENSATION LAWS Of N <br /> APPLICANT'S SIGNATURE: _ TITLE S; 4ed DATE <br /> CONDMON(S): I• `--w" � P <br /> EH 23 046 (Revised 9/11/96) Page 3 _"_Z <br />