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Y <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 SHAD/ED AREAS. INDICATE PERMIT TYPE BELOW: <br /> I,(,JCi. <br /> REMOVAL TEMPORARY CLOSURE CLOSURE I�II]JJ�"PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # M v--IS ,r b f <br /> F FACILITY NAME PHONE # <br /> A <br /> C ADDRESS 3 Q v <br /> I <br /> L CROSS STREET <br /> I 7 C�, �} <br /> T OWNE /OPERATOR {{,�`��✓� // !! PHONE #?iO�I— <br /> C CONTRACTOR NAME L � 1 I r�' �,.t , � f� PHONE <br /> �I/QS L6i ✓ 1}(z <br /> N CONTRACTOR ADDRESS 0 I CA LIC # CLASS <br /> T � <br /> R INSURER . #^ I ;, . .... WORK.COMP.# <br /> C FIRE DISTRICT 4 .r� �,Yy PERMIT # <br /> T 'i ,, ,.�1-rY�, <br /> 0 LABORATORY NAME PHONE # Y <br /> R <br /> SAMPLING FIRM PHONE # <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED. APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / / ` (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME `',. �+�! DATE /0 <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 COMPENSAT OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERF !MANCE K FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF C L FOR " <br /> APPLICANT'S SIGNATURE: TITLE `/t(� S DATE <br /> OL ►1u IL A kms- uta <br /> �7i�vt4� av d <br /> EH 23 046 ~3Revised,7 10/92) J Pa 3;2j <br /> j1 f <br />