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94 APR 13 PH 2: 8 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND NAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM T� IROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> E VTjALdTEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT i TELEPHONE # <br /> F FACILITY NAME PHONE # <br /> A <br /> C ADDRESS <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y `P uJq Y' fi <br /> C CONTRACTOR MAKE PHONE Gj PHONE $' Z-{�O j Z <br /> 0 <br /> NCONTRACTOR ADDRESS 009 CA LIC # Z? CLASS <br /> T <br /> Ro <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY N PHONE # <br /> R <br /> SAMPLING FIR PHONE # <br /> T K ID # T K SIZE CHEMICALS STOR B CURRENTLY/P EVIOUSLY TE UST INS LLED <br /> 39- <br /> 39- <br /> rA 39- <br /> N 39- <br /> KK 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A - CMATTACHMEWT WITIC CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> IilillitittllI 11111 IMIM I I HIII I I I I IIIIIIIH111111111111111 111111 t#111 III I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAMUIN 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 SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKERS COMPENSATION LAWS OF CALIFORNIAN CONTRACTOR'S MIRING 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 WORKEROS <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> EH 23 046 (Revised 7/10/92) Pape 3 <br />