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• � .. a �• I � , <br />SAN JOAQUIN COUNTYPUBLIC HEALTH <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERM] <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />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 />CONDITION(S): I , Fz&o <br />4,01 (-16 kAws4 <br />. o <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # V"I 3 PROJECT CONTACT & TELEPHONE # <br />L J <br />F <br />FACILITY NAMEN <br />PHONE # <br />A <br />C <br />ADDRESS <br />- <br />5 3-3 4o <br />I <br />L <br />CROSS STREET <br />a <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />I <br />C <br />CONTRACTOR NAME <br />PHONE #rI ® <br />q6l — b337 <br />'T <br />a� <br />0 <br />N <br />CONTRACTOR ADDRESSgS-_35 CA LIC # <br />DA <br />® ® <br />CLASS <br />AA4AlVLAlyN <br />T <br />R <br />INSURER 3 <br />WORK. COMP. #A ® 41 ., 8 <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME COUNTY <br />PHONE #�-/ ® 7 ® ®lam <br />R <br />111111111111111111111t111111tt <br />SAMPLING FIRM ® <br />PHONE # <br />TANK ID # TANK SIZE CHEMIC <br />RENTL&PREVIOUSLY DATE JJST INSTALLED <br />39- 14000 <br />T <br />39- <br />' + <br />A <br />39- <br />++ <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />APPROVED WITH CONDITION(S) <br />DISAPPROVED <br />(SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />ILAPPROVED <br />PLAN REVIEWER'S NAME <br />DATE <br />111!1111111tllltlltllllllilllllllllllllllli1111111lItll{Illlllltllltlltlitlltlllllllllt111111!ttlilllillllllltllltlltlflllltl <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 <br />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 SIGNATURE: TITLE <br />• y DATE <br />CONDITION(S): I , Fz&o <br />4,01 (-16 kAws4 <br />. o <br />EH 23 046 (Revised 9/11/96) Page 3 <br />