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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVA:TE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> �c REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # ('�8z 1 2 w S 3 Z PROJECT CONTACT & TELEPHONE # MAu.RIGE-56,15014 Lloct)q 6 Z—Z078 <br /> F FACILITY NAME5HARPE PHONE # <br /> A -0.L-A . -£f6rs5E-Pis-r. DEPor SAN JOAo.%l14 SITE (zo9)a8Z-2078 <br /> C ADDRESS 7O0 E . Rortt R-p. LA- HRoP, CA 45330 <br /> I <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR U.S. GOVT PHONE # /209) 4 8 2-20 78 <br /> Y L <br /> C CONTRACTOR NAME CAL.L �i�J C PHONE # (70T)44(o-79U, <br /> 0 2040 VCAlBoPy P.D. '4av <br /> N CONTRACTOR ADDRESS V^C^vt`LC CA AS68' CA LIC # &57-15-,q CLASS A 13Asg HAZ <br /> R INSURER WORK.COMP.# (J W G H$'t7o$'(,-c) 2 <br /> SURE r,t 3s,�a 5 J.La,T a a L,. A" Cok" <br /> Aa G <br /> C FIRE DISTRICT -1). ( U! 0 ;z j qq�)-- PERMIT # <br /> T <br /> 0 LABORATORY NAME 1jJ NTY _ W PHONE # S� <br /> R <br /> SAMPLING FIRM (� PHONE # <br /> 111111111111111111 1 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- { 13I77) 910 11 CM 0 <br /> T 39- <br /> A 39- <br /> N 39- -- !93O <br /> K 39- 2. ®® 70 <br /> 39- rld�svr �jl f <br /> 9- 7 4 -- <br /> I <br /> 31- T—*1 (s �50 Ga0.` y` (4701' <br /> APPROVED PROVED WITH CONDITION(S) DISAPPROVED <br /> E CONDITIONS BELOW AND/OR ON ATTACHMENT) rr <br /> PLAN REVIEWER'S NAME DATE <br /> I <br /> fill llllIII lllllllllllllllllllllllIII llllllllllllllllllllllllllltlllllllllllllll111111111111111111111111tllllllllllllllllllll. <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." /� M <br /> APPLICANT'S SIGNATURE: TITLE /ROcIECi 'r+-VA4eA- DATE L5 Q <br /> CONDITION(S): / <br /> p/ -5,,p <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />