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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> . ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CAD' PROJECT CONTACT $ TELEPHONE # S,}.�� �S 7p7 _-) 4 <br /> AF FACILITY NAME 16 r- �"� PHONE # 09 _Z <br /> ADDRESS <br /> I -ay X7 <br /> W w 33 <br /> L CROSS STREET S. A r 4 n <br /> I <br /> TOWNER/OPERATOR PHONE # <br /> Y � r <br /> ASP -✓q 1., y.J G. -876 i <br /> C CONTRACTOR NAME LPHONE # <br /> 0 -7121 - t{y(p--)c 140 <br /> N CONTRACTOR ADDRESS 0 '7q CA LIC #`�--r-7 ICLASSA <br /> T <br /> R INSURER LLC. ,e -&mao $.1 " �� 1 au 'CELQ ^f <br /> WORK.COMP # oo,(/v goo - <br /> A U <br /> C FIRE DISTRICT T fZbtx \ 1ta ` PERMIT # <br /> T <br /> 0 LABORATORY NAME No{�� <br /> R &VIlopCOUNTY 15p,.j PHONE # �' 5M- <br /> -SAMPLING <br /> SAMPLING FIRM CAL- --,roc- PHONE # -7p-) ggG_7�9( <br /> 111111111111111111111111111111 <br /> TANK ID # TANK SIZE CHEMICALS STORT CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- "Disse! <br /> T 39- <br /> A <br /> A39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED _ APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <br /> 111111111I1I11111111111111[111111111i111I111i111111I11[11111111111I111i11111111111I11111Il11I111i1111111111111111111111111111 � <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 IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING- <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE TITLErO% D J DATE 1119% <br /> CONDITION(S): <br /> • <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />