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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 TH PPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> _ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> FPA SITE # 2 PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME l PHONE # 4z/ I�,3 <br /> 1 ADDRESS (��i• __51 - <br /> I <br /> L I CROSS STREET ��O _ <br /> I PHONE # <br /> 1OWNE OPERATOR G Z <br /> Z- P <br /> PHONE <br /> C CONTRACTOR NAME •--tA <br /> N CONTRACTOR ADDRESS Q O , CA LIC # CLASS O <br /> T t� WORK-COMP.# 8 6 <br /> R INSURER � <br /> 117 <br /> A L PERMIT # <br /> C FIRE OISTRICT� <br /> T <br /> ILABORATORY NAME PHONE lo ­r7gg- <br /> SAMPLING FIRM G'' EO (�T -TT<- � 5irz v7 r� PHONE --02� <br /> ANK I tN I TANK SIZE CHEMIC S STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK ID # u <br /> t 39- S 55bC+✓"I-C-L-O � � <br /> A 39- <br /> H 39- <br /> K 39- <br /> 39- <br /> 39- I lfmTffffmffmTmllllllllli <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED G �9 <br /> A (SEE ATTACHMENT WITH CONDITIONS) DATE <br /> N PLAN REVIEWERS NAME III um 111111111111111 <br /> Jill <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 WHIG THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT 10 WORKER'S COMPENSATION lAW -,OF CALIFORNIA-" CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "1 CERTIFY THAT IN THE PERFORM O _ HE WORK FOR WHICH CH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO YORKER'S <br /> COMPENSATION LAWS OF CAL1 •" -`� <br /> APPLICANT'S SIGNATURE: TITLE <br /> ,�(;� yt <br /> EH 23 046 (Revised 7/10/92) HD Tri nw *o <br /> Page 3 <br />