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7 <br />0 <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />ANCE <br />TANK <br />APPLICATION XPPIRESN90TDAYSPOFROMYTHEOAPPROVALCLSURE ORA <br />DATE. NM <br />NOT WRITE OFUNDERGROUND <br />ANYYESHADEDDAREAS. NDICATETPERMIT STORAGE <br />BANDOENT IN PLACE TYPE BELOW: <br />THIS PERMITT EE <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />PROJECT CONTACT & TELEPHONE # J N�QA 0116-17Z- ` l q <br />EPA SITE #LA6 00oC-), ta,167 �� ���_ � �l� o <br />PHONE # 7(j <br />F FACILITY NAME (��yGe�/�Qb,y �lGP�✓/C s�o'a T <br />A <br />C ADDRESS G Al. /44"L.�.� Cc <br />�� <br />L CROSS STREET 1-0 CK. Fo?,D .ST/ f�' PHONE # j <br />T OWNER/OPERATOR CReop i 'u A / �(�J Pvnf � - ���rd 6- �z 133 -pv6� `lO <br />Y / PHONE # 6(Q <br />C CONTRACTOR NAME fj W-,jj5,(o N►ST f -XV P hJC CONTRACTOR ADDRESS CA LIC # / 77 Z �e CLASS 8 crrt�, uyOr f} <br />°(7 ( Sea a f� (3�v�( - <br />,N 3q ��C �aq <br />T WORK.COMP.# G a <br />R INSURER �,< la- PERMIT # <br />C I FIRE DISTRICT PHONE # <br />T <br />0 LABORATORY NAME G_ y Z7 <br />R O�CC�{.,S�If�E �V�C.C%C�MFi�'J•� PHONE # ��� '""�.6-/-�� <br />SAMPLING FIRM <br />11111111111111illllillli111111 TANK SIZE CHEMICAL STORED CU RENTLY/PREVI SLY DATE UST INSTALLED 7 <br />TANK ID # SUP (j , J6 G lJft <br />39- It3 m0 it cc <br />T 39- l0 00 i G <br />A 39- — d®�^ �t�U _ 1IVn4��it; ®lt� <br />N 39- <br />K 39- <br />39- <br />39- <br />1lllitlfllll! Illllililfllllll Iillillillll111111111111111111i1lillllilllllll111111111lII1illlll! 111111IIlIIl1111111 <br />P APPROVED WITH CONDITION(S) DISAPPRoveo <br />L __ APPROVED <br />(SEE ATTACHMENT WITH CONDITIONS) DATE <br />A 1l111fTTfTfTffTl <br />N Illlllilliitllllilll <br />PLAN REVIEWERS NAME <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUILICENSED <br />COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEFORHWHICHSERVICES. <br />THIS PERMIT OROIS ISSUED, IASHALLSNOTSIGNATURE <br />EMPLOY ANYCERTIFIES <br />PERSONTIN SUCHOAIMANNERIASETOIFY BECOMETHAT <br />IN <br />THE PERFORMANCE OF THE WORK FOR <br />SUBJECT TO WORKER'S COMPENSATION <br />NCLAWS <br />E OF OOF CALIFORNIAWORK FOR WHICHONTRAC ORMITHISIISSUEDSUBCSHALL CEMPLOY TING IPERSONS SUBJECT GNATURE ETO WORKER'S <br />S THE WI <br />"1 CERTIFY THAT IN THE PERFORM <br />COMPENSATION LAWS OF CALIFORNIA.," %/ <br />TITLE � " `- DATE !/ <br />APPLICANT'S SIGNATURE: � ! <br />Page 3 <br />EH 23 046 (Revised 4/26/94) <br />