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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 FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL Y CLOSURE CLOSURE IN PLACE <br />EPA SITE # PROJECT CONTACT & TELEPHONE # J -Ac K. 7 - (,-5q G <br />FACILITY NAME M I,'v k NAA" PHONE # <br />ADDRESS 1 O� y �1� rre-r <br />CROSS STREET <br />0WNER/OPERATOR PHONE # <br />C CONTRACTOR NAME ,U •.-V i Z"J �-,4 � / n� PHONE # <br />0 _ <br />N CONTRACTOR ADDRESS 4� j6� J Ni F9-*! t i ce• C��; CA LIC # C�/�-' t.,�� CLASS A - Ptd Z <br />T c. <br />^� <br />R INSURER �.� i-1 j. 1�SV`�NC�E WORK - COMP .` <br />A l <br />C FIRE DISTRICT �} IN !u® PERMIT # <br />T <br />0 LABORATORY NAME A A -r PHONE #-`'�®�� <br />R ��g <br />SAMPLING FIRM Q J�Gt.-` , PHONE # <br />111111111tflllllfili�l!!fl i <br />TANK ID # TANK SIZE CHEMICALS Sj X CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39-_ - O{ <br />T 39-4 - l- is s Ll. Mc.'Tcst <br />A 39- _ ci -rp ����, IXC Mi'si". <br />N 39- <br />K 39- <br />39- <br />39- <br />i111 T <br />P <br />L ROVED WITH CONDITIOMIS) _ DISAPPROVED <br />A E ATT T WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE S it <br />111111111 fill IIIIII I fill ilIIl I I I if 11111 liffillimfflum <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JCMtN 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: 111 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 PERFORM <br />ANq OF THE WORKWHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF IA. <br />APPLICANT'S SIGNATURE: t(1i TITLE_ OA <br />EH 23 046 (Revised 7/10/92) Page 3 <br />