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U <br />C <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 />k REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE #t"O on 2 6 PROJECT CONTACT 8 TELEPHONE # S a (�- Z <br />F FACILITY NAME I[-))`� T 'C PHONE # <br />A � I <br />C ADDRESS 31�� f l ��� n tjP� stocA A <br />I <br />L CROSS (.-tn�Su rJ 1 fP rT <br />STREET <br />T OWNER/OPERATOR ?w"- c bt�l PHONE # SID 8�3� <br />Y <br />C CONTRACTOR NAME _ PHONE # 0 (6 381-160() <br />0 <br />N CONTRACTOR ADDRESS 6goqC r I CA LIC # tZ-C4Mo CLASS A _ Fict u Q <br />T WORK.COMP.# Pwc 192.11 go I <br />R INSURER � ouen alA If <br />A�^ PERMIT # F%'t Pee to -i ► iuc un i( <br />C FIRE DISTRICT `-� Qf S� 0ee <br />T (/� (_ PHONE # <br />0 LABORATORY NAME f On OG t L v fq Orb ��� S�� �Is -7 <br />R PHONE # <br />SAMPLING FIRM 'L Q nVtr0llmtJ. ' SE'rVtt tJ ($"10 �.Z®��7� W <br />I1t1111t1lTANI lllltltttltltl <br />TAN ID # TANK SIZE CHEMI LS �StTORfD�CURRENTLY/PREVIOUSLY DATE IUST �INSTALLED <br />39- I � - DD o. 'tF J1 <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />Il11 � <br />P <br />L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A(SEE ATTR HMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME ® DATE <br />Illlltltllitlllllltl 1!111 <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 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.'" , ��;� <br />� �J.�/V"`- HGVYNI��-� TITLE LL !AW DATE <br />APPLICANT'S SIGNATURE: t - --�— <br />EH 23 046 (Revised 7/10/92) Page 3 <br />