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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 TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # PROJECT CONTACT & TELEPHONE # <br />FACILITY NAME iti t MARZ PHONE # t <br />ADDRESS (OV V0522 - <br />CROSS STREET T <br />OWNER/OPERATOR PHONE # <br />C CONTRACTOR NAME+ <br />tFpjV(aor,)Mr _r0 zt JAL_ <br />PHONE # <br />N CONTRACTOR ADDRESS l CA LIC # <br />CLASS <br />T <br />R INSURER l.� Lg <br />A <br />WORK.COMP.# <br />C FIRE DISTRICT <br />T <br />PERMIT # <br />0 LABORATORY NAME <br />PHONE <br />R <br />SAMPLING FIRM <br />IIIIIIIIItIIllilllll 11111 1 <br />PHONE # �. <br />TANK ID # TANK SIZE CHEMICALS S ED 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 1111 n <br />nj (� <br />L APPROVED APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />A J TTACHMENT WITH CONDITIONS) <br />_ <br />N PLAN REVIEWERS NAME <br />11111111111111111111 <br />GATE <br />11111 III Fl <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />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 />FOR <br />"I CERTIFY THAT IN THE PEROF THE WORK WHICH THIS PERMIT IS ISSUED, <br />COMPENSATION LAWS OF CALIF IA. <br />I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />APPLICANT'S SIGNATURE: <br />TITLE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />