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l� <br /> ENvIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> 1.1'f'1ICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> fNIS PERMIT EXPIRES 90 DAYS;FROM THE PROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELDW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> t'PA SITE R 0 5Z PROJECT COIiTACT i TELEPHONE M M _ <br /> I IACILJTY NAME - LL [ , 1 L PHONE <br /> aU1)RtSS � a i (� s <br /> I (-ROSS STREET �' UL _._..--.._ <br /> i (iuNFR/OPERATOR PHONE S <br /> (1f1 DNrkso q q <br /> PHONE I ZO <br /> (:ON TRACTOR NAME `,�k O [-� C <br /> ri CA LIC SIva CLASS L' <br /> C0111RACTOR ADDRESS 36 Ian �ZU -:-/- <br /> R WORK.COMP.# C <br /> IN'SURE <br /> :. <br /> IiHl DISTRICT ,.f PERMIT Y <br /> ii I A(WRATORY NAME C� PHONE /5%Q-?C! <br /> SAJAPi,I NG FIRM [r trrT V PHONE iT2p�'] C� 7 <br /> �t���irrr�rru�r �nu�Ti�� <br /> TANK 1D * i Sl? CHEMICALS STORED CURRE111ILVaPRIEVIOUSLY DATE USI IN51> I:t• i <br /> 59- <br /> A <br /> 9 A 39-_ <br /> If 39-__ <br /> is 39-_ <br /> 39--, <br /> 339i�rrrmi R Rrmrr��nriir��i�i <br /> APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> (E ATTJICNNENT WITH CONDITIONS) <br /> u MAN REVIEWERS NAME ' ! DATE <br /> �i�i��rrrrrrrrrr�trr D Trr t»mrr��rr�rrrtir�ii�� <br /> �:I1'LICANS MUST PERFORM ALL WORK 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RALES AND REGULATIoils 01 <br /> nr+ JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER Gil LICENSED AGENTiS SIGNATURE CERTIFIES THE FOLLO{11NG: "I CERTIFY THAI IN <br /> Ili( FERFORMAHCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT ENPLOY ANY PERSON IN SUCH A MANNER AS 10 BECC4L <br /> 11 C1 10 WORKER'S COMPENSATION LAWS OtEHIA -CON CTOR,S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES 1HE FULL r.11.. <br /> "I (ARTIFY THAT 1N THE PERFORMANCE O E WORK FOR WHICH THI RMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 10 WORKLA'.: <br /> 111111'1-HSAT ION LAWS OF CA 1 <br /> ( iCANT'S SIGNATURE: TITLE DATE <br /> r. <br /> to 75 046 (Revised 7/10/92) Page S <br /> 4 <br />