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c,/ <br /> ENVIRONMENTAL HEALTH DIVISION IPI S <br /> APPLICATION FOR UNDERGROUND STORAGE T <br /> APPLICATION FOR PERMANENT/T T 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 v/�^7 o`,4� <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # ,901- 2 <br /> F FACILITY NAME �SO� ` _� PHONE # <br /> A <br /> C ADDRESS <br /> t <br /> L CROSS STREET <br /> I PHONE # <br /> T OWNER/OPERATOR 2�/- <br /> Y -0 6?y. <br /> C CONTRACTOR NAME kS 60 PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC CLASS <br /> # 3 5 5 <br /> T WORK.COMP.# <br /> R INSURER <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAME PHONE # <br /> R PHONE # <br /> SAMPLING FIRM ��;; <br /> TANK <br /> 111111l111111ilititiil i <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39-- <br /> 39- <br /> p <br /> L __ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111IIIIIIIIIIIII11111 <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 PER FORMA E OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI / <br /> APPLICANT'S SIGNATURE: TITLE l� / DATE 2 <br /> SCAB <br /> EH 23 046 (Revised 7/10/92) Page 3 PAYMENT <br /> RECEIVFn <br /> FEB Q 4 163 <br /> SAN JOAQUIN COU+v rY <br /> PUBLIC WEALTH SEROCI-S <br /> . �VIRONMENTAL HEALTH Ui'vsuiON <br />