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�Q <br /> JUN: 0 3 1993 <br /> EN\ARONMENTALHEAL ENVIRONMENTAL HEALTH DIVISION <br /> PERMIT/SERVICES <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 /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # C'A(� q Flo 893 ss (o PROJECT CONTACT 8 TELEPHONE # (,GY rY1AR s►-�q Ll_ <br /> _ has- 3aa i <br /> F FACILITY NAME YYIAIvT�CF� VNI FIE, SC 400 �ISTdZIGT PHONE # <br /> A 1.1'711 <br /> C ADDRESS a01 0 I ` () V I SF V`E- <br /> , <br /> I <br /> L CROSS STREET I R Qp R-T W A y <br /> I <br /> T OWNER/OPERATOR 7�' /� 1 ,� <br /> Y M(MTICA UNI FI FSO SC400 L. PHONE # <br /> g a s- 3a a I <br /> C CONTRACTOR NAME <br /> 0 'S 1E Mc0 PHONE # Say - q 653 <br /> T CONTRACTOR ADDRESS 17 VbNT4 # yy� g 6L4 CLASS A)3, 0- ) <br /> R INSURER ` S`(-�wA Q 1 <br /> A WORK.COMP.0 LA)t7 P31a by-)I) <br /> C FIRE DISTRICT 1'�'lANTECA � ��-T-��OQ Fi2�, t��(l7j PEI'Mr <br /> T V <br /> fSAMPLING <br /> 0RA70RY NAME v A� LrY� `. ` �R3o�pA/�� 1 S PHONE # a Q L�_ 5-7;)- ()90U <br /> FIRM - ANALYTICAL LPrSo RATa(ziES PHONE # aQCI`_ S7a_ OgO� <br /> 111111111111111 111111111 <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY <br /> 39- IIS%- GATE UT INSTALLED <br /> T 39- � o Z I a , 00 0 CGALLo�1 D I b sf L. Fu c t 9 UST <br /> i <br /> A 39- SS 1 e1+ °e° '' C�AsowtyL ►°17S <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 11111111111 1 ffffn fill III III 1 1111111111 fill 111111111 <br /> YY �r1+ <br /> L I\ APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED <br /> A _�LrSEE A NT WITH CONDITIONS) / <br /> N PLAN REVIEWERS NAME ?jam DATE b -191 <br /> Illlllllillillllilll Iilii <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 CALIFORNIA." <br /> APPLICANT'S SIGNATURE:14 L )L-J�P TITLE �� ( SID T DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />