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ny <br /> e op y <br /> I Y iwu's•� � <br /> ENVIRONMENTAL HEALTH DIVISION JAN 19 5 5 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ENVIrrRpp�AG£ <br /> O��NTM//ENT,n,I HEALTH <br /> APPLICATION FOR'PERMANENT/TEMP RY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE;-; "FEkk.l ES <br /> THIS,PERMIT EXPIRES 90 DAYS FR THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED R S. INDICATE PERMIT TYPE BELOW: <br /> MOVAL TEMPORARY CLOSURE CLOSU E IN PLACE <br /> EPA;SITE # E PROJECT CONTACT & TELEPHONE # Z09— <br /> FACILITY NAME, , �� \ PHONE # ZO ' G <br /> t t <br /> 'ADDRESS <br /> I V <br /> CROSS,'STREET•,,;,i;'. <br /> OWN E /OPERATOR'' '+.' PHONE #yD9— <br /> CONTRACTOR NAME' PHONE tl�D ''� Q 9 Z✓ <br /> I CONTRACTOR:{ADDRESS0 CA LIC # CLASS <br /> 2 INSURER I'�.;i �P' 7"'Iir."rrf.: 7, WORK.COMP.# <br /> lr -1 �� _ . <br /> FIRE'.DISTRICTs' 2''r l <br /> Y PERMIT # <br /> I <br /> LABORATORY-NAME PHONE # <br /> SAMPLING':FiRM'!•, '` PHONE <br />- 111111111111111111111111111111 <br /> TANK,;ID # TANK SIZE CHEMICALS STORE URRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br />- Illl i I i lylll IIIIIIrrlillt lI II <br /> PPRO APPROVED WITH TN CONDITION(S) DISAPPROVED <br /> i (SEE A ACHMENT WITH CONDITIONS) <br /> PLAN REVIEWERSINAME-1 'I ' —� <br />- I I I l l l l l l l l l l l l l t l l l 1TITiTiTTI DATE <br /> I11a'frrlq <br /> APPLICANT MUST PERFORM;ALL',WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND R LATiONS OF <br /> SAN JOAQUIN COUNTYrPUBL!IC':HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I C FY THAT IN <br /> IHE PERFORMANCE OF'THE,WORK FOR WHICH THIS-PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS T COME <br /> SUBJECT TO WORKER.,S" OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES T FOLLOWING: <br />"1 CERTIFY THAT IN,THE PERF MANCE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WO R'S <br /> COMPENSATION LAWS OF'CALIFOR M," �_ <br /> 1PPLICANT'S SIGNATURE:'. _ TITLE A S DATE <br /> vn,4 co V, —c�� <br /> SJJ/ZICIL�tM S (IrLL J Jw��.l,� rl61.J.'_/G <br /> l/ <br /> 23 046 (Revised 741011n) / Page 3 V <br />