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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 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 DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # Ue_t Cq,-83�_ Lk4� ( <br /> v <br /> F FACILITY NAME - ` ( � Q��u �`� PHONE # <br /> ! Ar <br /> IADDRESS 6-\�� ``v c`V el- <br /> L CROSS STREET <br /> I <br /> T OWN E OPERATOR PHONE # <br /> C I CONTRACTOR NAME �. � � ', U LpS PHONE # .,C 6 <br /> N CONTRACTOR ADDRESS C- YY1e rC �C` S CA LIC # 1> ] CLASS �� S <br /> T <br /> R INSURER WORK.COMP.# <br /> S��a-}� �L� <br /> A <br /> C FIRE DISTRICT F4, PERMIT # 1,V4�IJe� <br /> T <br /> 0 LABORATORY NAME U, } COUNT F,, PHONE # C)<6_ q (o <br /> R l T'" PHONE # s - <br /> SAMPLING FIRM ��..,,�\ �� \1V !1 mpvITA` L'lj\C.E'S �V�C - �J j <br /> I I1111111111111I11111141111111 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- C^c���o+\ ":mac-1 I`i1`F <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 11111111111111111111111111{111 11111111itllllillllll llllillilll Ill 11 llil lllllllill lltlltl1111111111111 1111111111111111111{{ <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <br /> IIIIIIIIIIIIIIIIIIIIIIiillflllllllllllllIllillllllllillilllllllllllllllll{IIIlilliltlllliltllll{Illlllllltlilliltlllllllllllt <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 PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI " q <br /> APPLICANT'S SIGNATURE: LA)J TITLE CJ i` �� DATE <br /> CONDITION(S): <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />