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0 • <br />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 APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # � � PROJECT CONTACT & TELEPHONE ,C�k)J,I;V-:7 <br />F FACILITY NAME !��-1E-�,✓L�%�� TC7+� = j G • L PHONE <br />A <br />C ADDRESS���C' <br />I _ <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR ) �Se,:2oj Z a Z_ -L= S PHONE # <br />C CONTRACTOR NAME / �--�d�i �,� CQ PHONE <br />N CONTRACTOR ADDRESS `S�f I �C �J CA lIC # CLASS <br />R INSURER �Z� y'� WORK.COMP.#��� - GCC' C <br />A T �Cr>d ,Frf .�4r"i%% C_ ��% `� t /OZ� �l mit'-G= <br />C FIRE DISTRICT PERMIT # _ C' <br />T <br />C LABORATORY NAME >E�C,.a1Ji COUNTY PHONE # <br />R <br />SAMPLING FIR _ PaHONE # <br />TA K ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE lJ$INSTALLED <br />39- Q �OGo ldl3� T� LJ y <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39-- <br />39- <br />P <br />L _ APPROVEDAPPROVED WITH CONDITION(S) _ DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME DATE t3 <br />III 11111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 <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 INTHE PERFO CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF NIA," <br />y' <br />APPLICANT'S SIGNATURE: TITLE DATE — <br />c' j- 71 <br />CONDITION(S): / <br />��,..,,,,..n.�-z.r�� �.�-��rk..- .Q �� , j,,.� �.,s� �c�i�.- • /�'t,� c�-f �� ;�I <br />�6k <br />EH 23 046 (Revised 9/11/96) s�e Page 3 <br />