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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 THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />�r REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # C4Q�'�� ,��PROJECT CONTACT & TELEPHONE # " YZi'r '� <br />F FACILITY NAME"-, <br />,/�} <br />r PHONE �c tAl ,.- L' C7 <br />C ADDRESS 7 (' L � f <br />L CROSS STREET <br />I <br />PHONE # <br />T OWNER/OPERATO , ^,�-: • �_. �° <br />1 14 Go 7 <br />Y ! '� C a I �._ <br />C CONTRACTOR NAME PHONE <br />N CONTRACTOR ADDRES �a�� zX ��,Ir���'• C�C L�Y�" CA LIC # /'L�) V CLASS <br />a L t%j j !I c( (% � i <br />T <br />R INSURER �� WORK.COMP.# Cj' f_,_�� . <br />A <br />C FIRE DISTRICT = ��� �.! �jY PERMIT # <br />T ( 1 <br />0 LABORATORY NAME('' <br />R f;'Gi �i�i i -Vo 1, o�CL1i t'ICCcwl PHONE #� <br />SAMPLING FIRM jj}} 11��� t6�C', l��Yi (:<<,y PHONE <br />Ilillilllllllllll�l� �Ill�ilfl <br />TANK ID # TRK SIZE CHEMICALS STORgD CURRENTLY/PREVIOU lY DTE UST INSTAb,LED <br />T 39- r39- <br />� <br />A 39- , <br />N 39- < _4 CX' C 1 /i i.� 74 11 <br />G <br />K 39- <br />39- <br />1111111111111111 I I 11 111111111 �n IIII 1lillliillliilllllllllllillllll <br />P <br />L _ APPROVEDAPPROVED WITH CONDITIONS) _ DISAPPROVED <br />A 4(SEATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />I I I I Ill 11111111111111111111 Ill 11 Ill <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:2.� <=E� TITLE ATE / g <br />Cc)r,-c_kcfi.d►(\s of- PIP r -c->✓ <br />- j�o (!�� U t � ia � K;S <br />�o lb dl�� t t, 0005 5 re��t 1 q'4, . <br />2� e�ot�5 ire( c«�e -pvv -T,�-1 `ice lis L h pec( C�a a� <br />-� e.f�� / CL" fckxALLS 5hv ld <br />oS <br />EH 23 046 (Revised 4/26/94) Page 3 <br />