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3Off <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 Ti�E APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />�(/REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />ti1 •tT.E;# 3 pO /-- / g 7 1 <br />PROJECT CONTACT L TELEPHONE # <br />F FACILITY NAME U4r/ZA►MA/L .. <br />A <br />C ADDRESS 3 GJ Iy _. f 4A e—k O K -C E L - ISI . LDS <br />I <br />L CROSS STREET GLM <br />I <br />Y OWNER/OPERATOR <br />Cl CONTRACTOR NAME �� (� /V(� EN l►v� E.{C(�,4.I.j <br />O <br />N CONTRACTOR ADDRESS <br />T <br />R SRIgER vLfJl G jk - <br />A <br />C IRE` DISTRICT <br />T <br />PNONE # Z09,r 3�ps.. 1553 <br />PHONE #j''' <br />20` , — 583— 5 ✓3 <br />PHONE # <br />CA LIC 0611 z 3 $ CLASS A tip <br />WORK. COMP.# 2. el20(p b(pcj <br />0 <br />R <br />�.v <br />7tfY' NAME��--rP , �O N` M �t�17 - Jr�v�,�94 <br />#(vs�-zp� <br />( lboo) r�Z► -' (n -1 acQ <br />' <br />�;t',INO f•IRM �Gil�rQ�1+�Ot.IM+�N�T1�l� <br />r �rrrrrr,rnn��irinnnn <br />TANK lOr.T <br />39- Zt� < <br />}.z`�v <br />• <br />'A. # `80b) 5;'�[— 0-i8`° <br />I SIZE <br />< <br />Cell `S'TOR 0 CURRENTLY PgEYl00SLT <br />DAT ST INSTAL <br />uAw N <br />T <br />39- /57,P7 <br />UTKMVW NI <br />A <br />N <br />K <br />39- r <br />39- <br />39- <br />39- <br />7& &V +• <br />.GIAPWA7A4.i, 4*~UA/6 <br />Un AST <br />39- <br />P <br />L APPROVED PROVED WITH CONDITIONS) _ DISAPPROVED <br />ri�ll��L�r E TACNMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />rrnrrrnrrrtrnrnr11111,11111m]: II)TIIIIIIIIHIIII III 11T, <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCEWITH SAN JOAQUIN.000MTY ORDt 04JEATE LAGtSIF REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ER OR LICENSED AGENT'S U614 1`IFIgS TNl F �!!1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK.FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT E14P OY uY"PERS 1°''i RK AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIF IA." RA IS HIRING OR SUBC09TRACTING SIC''R .0 11FIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERFORMANCE Of ,TARE%OR P,E MIT IS ISSUED, I SHALL EMPLOY PERSONS'. SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA."i // <br />APPLICANT'S SIGNATURE. x <br />EH 23 046 (Revised 7/10/92) Page 3 <br />TITLE 1,4W(/M5re1A14/N�D� 7 --??— <br />