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qpltlyz� <br />MAY.3 1 1995 <br />ENVIRONMENTAL HEALTH DIVISION EN �ONR �AL VICESn <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 />V REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # G'LI7 ?y PROJECT CONTACT & TELEPHONE # `����: <br />F FACILITY NAME � � i C L PNONElog) N6 -� <br />A <br />C ADDRESS 19 l C C� <br />I <br />L CROSS STREETtil �� Citi <br />I <br />T OWNER/OPERATOR PHONE A � ,n d <br />Y J �qt�t-� �lJ 1 <br />C CONTRACTOR NAME I �� "PHONE #C� <br />0 <br />N CONTRACTOR ADDRESS i CA LIC # CLASS <br />T <br />R INSURER 5 WORK.COMP.# _ <br />A <br />C FIRE DISTRICT S, PERMIT # <br />T <br />0 LABORATORY NAME PHONE # S - OO <br />R <br />SAMPLING FIRM PHONE # +� <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DAT9 UST INSTALLED <br />39-'/ Z,t�CX) (.t v� L �.�1ee11 r•,oSni +L, /L <br />T 39 i 14 <br />- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />I111 � <br />P <br />L _ APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />11111111 IIIIIIIffflmll <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: 51"x- TITLE DATE <br />YI °( "qi edl <br />/fS- /jjJ <br />l CC <br />EH 23 046 (Revised 7/10/92) Page 3 <br />-AeMop, 3D i ce��'��- <br />