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666vvtlte.lf <br /> lQv <br /> JAN 2 8 1993 <br /> EN""ONMENT <br /> FERMR/SET VV H TH <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 /> V REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # oPROJECT CONTACT L TELEPHONE # <br /> A FACILITY NAME •- C� �- - t PHONE # c <br /> CADDRESS <br /> I <br /> L CROSS STREET I� <br /> r� �1 <br /> T OWNEMPERATOR PHONE # ZU <br /> CC- <br /> CONTRACTOR NAME ' �� PHONE # <br /> O <br /> H CONTRACTOR ADDRESS �� U - CA LIC # �G?!a� CLASS <br /> T <br /> RA INSURE ?.� .: dM WORK.COMP.# f <br /> C FIRE DISTRICTt e.T-GC ,� rt r PERMIT # I <br /> 7 <br /> 0 LABORATORY NAME C -�: PHONE Q.- ���6 2 j h <br /> R SAMPLING FIRMPHONE # <br /> rrrrrnrrrrrrrrrrrrrurrr�urr ��_�. 7 17s <br /> ANK ID # TANK SIZE CHEMICAL TORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED �I <br /> 39- LSURc L,, --- <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> rrrr <br /> L APPROVED APPROVED PITH CONDITIONS) DISAPPROVED <br /> A E ATTACHMENT WITH CONDITIONS) } 1 7 Q <br /> H PLAN REVIEWERS NAME DATE a. ev% / <br /> rrrrrrrrrriirrrrlrjr lrrrr <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 I$ ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE ERFOR OF E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CA F IA ----� <br /> APPLICANT'S SIGNATURE; �" TITLE ������ DATE <br /> cz <br /> l �b GP_e5�7. n�i`4&,t-,- _�.a'L'c_raYc� Sl�G i <br /> /�Z-_ . <br /> ' (Revised 7/10/92) Page 3 <br /> I <br />