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70 <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 /> EPA SITE # �� �� J 7 PROJECT CONTACT i TELEPHONE ! j o�� 1 N G N �D - ' 07,57 <br /> AFACILITY NAME/`f T �G� - PHONE <br /> ADDRESS Lc l�f}�tlr L/If ��d C <br /> L CROSS STREET <br /> I <br /> T I OWNER/OPERATOR PHONE # { <br /> Y <br /> C CONTRACTOR NAME L� <br /> 0 N�l 1�7- `"PiV L'/v I PHONE # Uct-t33-07r? � <br /> T CONTRAC70 #,--/-LR ADDRESS ({ #,--/-LVZ <br /> C 41� �� G LIC # ` O CLASS <br /> R ENSURER <br /> A - A4 l�z o WORK.CCMP.# d Z c1 7 <br /> rLASOP.ATORY <br /> RE DISTRICT AC PERMIT # <br /> 0 NAME ! Z PHONE # <br /> R s<a <br /> MPLING FIRM ` PHCNE <br /> iiiiitttttldtll %9 zaALZ Z <br /> TANK ID # TANK SIZE ,y CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST NSTALLED <br /> 39- / o r 4/ :�G c�C 4),v�Njcei., <br /> T 39- i � } <br /> A 39- <br /> N 39- r <br /> K 39- <br /> 39- <br /> 39- <br /> p <br /> 9-39-39- <br /> P '111111111111111m <br /> LAPPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME ZL/ (SEE ATT T WITH CONDITIONS) <br /> ((((illltt(llllttttt ffffil I I I HII I DATE Zo .4, —fj <br /> APPLICANT MUST PERFORM ALL WORK IV 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 PE9XIT 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 FOLLCUING: <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 CALIFORN • <br /> APPLICANT'S SIGNATURE: "1 <br /> TITLE i�r �f�v � DATE <br /> V <br /> EH 23 046 (Revised 7/10/92) Page <br /> s <br />