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1 0 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 />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE # NON t'i <br />PROJECT CONTACT & TELEPHONE # <br />Y <br />S 1 93 3 <br />F <br />A <br />FACILITY NAME <br />PHONE <br />! <br />ADDRESS1 S 1 IAIIIS �J� -0157, 2 POO <br />L <br />I <br />CROSS STREET <br />99 <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />0 r L COW) AS16 <br />is S-- 614!5— <br />C <br />0 <br />CONTRACTOR NAME ` <br />PHONE s7 4 q -7 ... Zq <br />N <br />CONTRACTOR ADDRESS es CO L)ICA I # 7G <br />CLASS <br />T <br />R <br />A <br />INSURER $ <br />WORK. COMP. # 5'7/- rtf:8 cIM2- -ku <br />C <br />FIRE DISTRICT i <br />V, <br />I <br />PERMIT # <br />T <br />, <br />y <br />0 <br />R <br />LABORATORY NAME V 0 iCA 1 <br />PHONE <br />SAMPLING FIRM FviaRO lL)L?5 ►�- 6-D <br />PHONE #(cf16) <br />TANK ID # TANK SIZE CHEMICAL$ STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />UIV L,n�Kuix%i� <br />T <br />39- <br />'q— <br />0--, <br />LjK)eLjo6gk2 <br />A <br />39- <br />Cg <br />U <br />UN)*:�\ <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />p <br />L <br />_ APPROVED _ APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A <br />_ <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />DATE <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 <br />EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE�TE <br />r6� <br />EH 23 046 (Revised 4/26/94) Page 3 <br />