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too 2v- Sc qco I <br /> �A ►�, roti -IL i' - -2�r� c2o s S <br /> b CCC k- 1 s �-,�' I � A,R]f6EALTH <br /> SERVICE <br /> N <br /> 93 JUN —7 Ptd ZI 09 <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 /> X�le�lQlr REMOVAL TEMPORARY CLOSURE _,_,_ CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT L TELEPHONE # <br /> F FACILITY NAME �+ PHONE # <br /> C ADDRESS <br /> 1 <br /> L CROSS STREET <br /> I PHONE # <br /> T OWNER/OPERATOR 393 <br /> Y f1,R tZ:o <br /> C CONTRACTOR NAME2 ^ 1 PHONE # <br /> 0 �. <br /> N CONTRACTOR ADDRESS k S 3`; V Sol af/ CA LIC # 33 CLASS <br /> R INSURER 0� '�Iv k WORK.CONP.#t/C 9-Z 6 7 7 <br /> ArD <br /> PERMIT # <br /> C FIRE DISTRICT 0( 1 �,� <br /> T PHONE # <br /> 0 LABORATORY NAME <br /> R PHONE <br /> SAMPLING FIRM <br /> TANK <br /> trr11!{1{1 !lllil111r1111 <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- <br /> A 39- <br /> N 39- r� <br /> K 39- <br /> 39- <br /> P <br /> 9-i1P <br /> L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A (SMATTACHMENT WITH CONDITIONS) <br /> DATE <br /> N PLAN REVIEWERS NAME <br /> 1{11111{11{1i11111iIffifflumall Ilium 1111till 1111111 jIIttM 1111 litttlill III I I IMIII li <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUSLiC 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 COMPENSATI WS OF CALIFORNIA." CONTRACTOR-S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERF, T K FOR WHICH,.TNIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER-S <br /> COMPENSATION LAWS OF CALIF <br /> � ��""�"� DATEr ?f S3 <br /> APPLICANT'S SIGNATURE: TITLE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br /> F-O'd G17S3T-29T6T O1 Wudd WUFT :TT +266T—LLF,—S0 <br />