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ENVIRONMENTAL HEALTH DIVISION m <br />.ILATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> Z <br /> c ° \ <br />.OSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK I 3 <br /> � <br /> fE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: '•' yy <br /> S Y <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE ________ J a z <br /> i <br /> PROJECT CONTACT 8 TELEPHONE # m z Q <br /> ] Z <br /> 3 N a A o <br /> PHONE # � • V W 0� mZ <br /> I S K <br /> IY 0 <br /> i 30 <br /> $ _ Ua <br /> PHONE # Lj <br /> r £ WS 0 Y <br /> PHONE # <br /> S <br /> CA LIC # CLASS <br /> O ; ¢N <br /> O tt o <br /> WORK.COMP.# <br /> V°- <br /> PERMIT # '3AY Nmou <br /> COUNTY PHONE # ae (r 1� ^t p =o /�I Y <br /> PHONE # O; • - 314 j a <br /> F <br /> •n 7 -) OG 0 0 <br /> ATANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 0 ^ p� Z <br /> o x •s'] Qr c9 a o °'z <br /> r---1 • III�j a o O <br /> O J W 6 H• <br /> 9 <br /> O0 U <br /> J ox N�0 =W <br /> e(_I <br /> >> <br /> III illi II �� ���� ��� �� �� ���� �� I'I—� m _ <br /> DISAPPROVED N w 0 UM U 1 – .I �iV <br /> PROVED APPROVED WITH CONDITION(S) I I ` I � <br /> (SEE ATTACHMENT WITH CONDITIONS) Ea <br /> DATE 0�- �' �- <br /> I1111 � n <br /> 0 <br /> �_ - - <br /> CCORDANLE WITH SAN JOAOUIN COUNTY ORDINANCE STATE LAWS, AND RULES AND REGULATIONS OF <br /> L J r <br /> VICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> H THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME G <br /> IS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING i` <br /> i <br /> IF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S �,� rN i ? G �.� '1� NIIMNYad o <br /> O <br /> TITLE DATE <br /> a y <br /> \ ~p <br />