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0 <br />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 />VTHREMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # I PROJECT CONTACT & TELEPHONE # C,__ _ _ .67. ,_ - J <br />F FACILITY NAME <br />A <br />C ADDRESS <br />I <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR <br />Y A.4A#,P <br />PHONE # 7 <br />zc,9, <br />'C CONTRACTOR NAME PHONE # t4A 0N CONTRACTOR ADDRESS CA LIC # S®1 <br />T QEg <br />R INSURER WORK.COMP.# <br />A <br />C FIRE DISTRICT ® ® / t PERMIT :. <br />T <br />0 LABORATORY NAME ! PHONE 6 <br />R <br />SAMPLING FIRM SS r�s� S �� PHON <br />tttttlltlllllllll Ttll <br />TANK ID # TANK SIZE ♦/CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />/—.14 <br />T 39- iii.. S7 A&L— Gl4s <br />A 39- O G24. 4 7A 06 C— CAS h <br />N 39- <br />K 39- <br />39- <br />tlil II I iiiTl 11 1 1111 1 Iltlllllll I 1 II111 III 1111 I I tllll 11 tll I I 1! TiiiifTl <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A E ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME - DATED <br />Illlllllltltlllllll! 11111 <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: 01I 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 SIGNATUR TITLE DATE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />