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?r CE - P11 2: 45 <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 />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE <br />I E! <br />F <br />FACILITY NAME _3 / /'. _ r <br />` <br />PH��HO' <br />OON # <br />ci <br />A <br />C <br />ADDRESS <br />I <br />LCROSS <br />STREET �" " <br />I <br />T <br />OWNER/OPERATOR C <br />PHONE # <br />Y <br />S <br />C <br />CONTRACTOR NAME <br />PHONE # <br />' <br />0 <br />N <br />CONTRACTOR ADDRESS�ieA <br />LIC #� C <br />CLASS <br />T <br />R <br />INSURER �.2L <br />WORK.COMP.# / ?S <br />7 r <br />A <br />C <br />_ <br />FIRE DISTRICT' ©� <br />PERMIT # 6 l <br />T <br />0 <br />LABORATORY NAME <br />PHONE # <br />R <br />SAMPLING FIRM S i, ��� / <br />PHONE # : 2--i 7 <br />7iv'L+ <br />1111111111111111111111 111111 <br />< <br />TANK ID # TANK SIZE <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE US7 INSTALLED <br />39- /a, O & V <br />T <br />39- <br />A <br />39- <br />N <br />39- L 21z d 4) tt;- <br />K <br />39- !on e, <br />L )<-/ <br />39- <br />39- <br />IIIIIIIIIIIIIII11111111111111111 <br />I IIIIIIIIIIIIIIIIIIIIIIIIIIilllllllllll IIIIIIIilllllilllllll <br />P <br />IIII11111111111111111111111111 <br />' <br />L <br />APPROVED APPROVED WITH <br />CONDITIONS) DISAPPROVED <br />A <br />^u (Sr TTAC,HMENT <br />` <br />WITH CONDITIONS) <br />DATE <br />N <br />PLAN REVIEWERS NAME C Lr <br />11111111111111111111 <br />11111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN <br />COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED <br />AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS <br />PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: L <br />TITLE j nP DATE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />