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• ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS :7REMOVAL E APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: TEMPORARY CLOSURE CLOSURE IN PLACE EPA SITE # CAP O2 1 ;5PROJECT CONTACT & TELEPHONE # PADiLLA 516 33 - F FACILITY NAME PHONE #/'20 3 A C ADDRESS ebC iG I L CROSS STREET I T OWNER/OPERATOR l5f %L l 0I 1. Com PSN 'Ir P Y O G751-6145 C CONTRACTOR NAMEOL"S PHONE # IO L� — 2L�. ° 5Fi% EXGHPrNG197 CDU9T S5 CA LIC # 'i,2 Q3 CLASS N CONTRACTOR ADDRESS R INSURER CJ F U Q WORK.COMP.# 511-14e) A C FIRE DISTRICT PERMIT # 0 LABORATORY NAME A WA 0 V - PHONE 01 1 9 2 CIOC) R SAMPLING FIRMU I N C, LpAvu EN PHONE # 8:211O IIIIIIIIIIIIIIIIIIIlulillllM TANK 1p # z K SIZ CHEMICALS STORED CURRENT Y/PRE IOU Y DATE UST INSTALLED 39- ~ J T 39- A 39- N 39- K 39- 39- 39- P L _ APPROVEDAPPROVED WITH CONDITIONS) _ DISAPPROVED - _ r SEE A CHMENT WITH CONDITIONS) N PLAN REVIEWERS NAME% DATE 1111111111111111111111111111 11 11111HIIIIIIIIIIIHII IBM APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: �"k��'�/ TITLE D tli� EH 23 046 (Revised 4/26/94) Page 3