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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 FROMTHEAPPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />M REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE #CAC 00 10 &o ?- S % <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY NAME �s1 <br />t / <br />PHONE #�! 2 ,, <br />1 J <br />A <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />le <br />zc, Y -- � <br />C <br />CONTRACTOR NAME / 1 <br />�c. <br />PHONE #914 .3 4PA <br />0 <br />N <br />CONTRACTOR ADDRESS �O <br />CA LIC # <br />Jf"� CLASS tfJ <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />PERMIT: <br />A <br />C FIRE DISTRICT f ( <br />Al 7 <br />T <br />'� <br />IP <br />0 <br />LABORATORY NAME ri_ <br />T �� <br />PHONE <br />6 <br />R <br />SAMPLING FIRM�SSe ,► <br />PHON <br />7 _ <br />IT11 <br />I I I I I I I I I I I I I I I I I 11 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE �iST INSTALLED <br />39- <br />9 <br />T <br />T <br />39- O Ga4•S <br />1dY1 <br />A <br />39- so ' LAS <br />C.(.hl p <br />N <br />- <br />39il 42 <br />K <br />39- <br />39- <br />39- <br />111111111111111111111111111111111111111 <br />lillllllllllllllllill <br />P <br />I11111111111111111111111111111 1111111111111lIIIIIII11111111111 <br />L <br />_ APPROVED _ APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />11111111111111111111 <br />DATE <br />II111 <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />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, <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNAT TITLE <br />DATE `J <br />EH 23 046 (Revised 4/26/94) Page 3 <br />