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' ,8,-r PoNLAo*- - • <br />• <br />I ENVIROMIENTAL HEALTH DIVISION <br />APPLICATION FOR PERMANENAPPLICATION FOR INDERGROMAID STORAGE TANK CLOSURE PERMIT <br />T/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND RA <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO HOT WRITE 1N µY SHADED AREAS.DW <br />HAZARD SUBSTANCE STORAGE TANK <br />j -1-INDICATE PERMIT TYPE BELOW; <br />REMOVAL TEMPORARY CLOSU,. <br />EPA SITE / gyp• A n ¢, RE <br />CLOSURE IN PLACE <br />(O�OOZZpj PROJECT CONTA ELEPHpIE / �a,n, <br />f <br />A ........ <br />...... NAME M� F 'S'i` aN <br />1q1 % <br />C ADDRESS <br />1 STac KTo1J 1 3� <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR <br />T 2 <br />PHONE M <br />C CONTRACTOR NAME <br />D }*.2 t3 (oSa - 4� <br />Q LF S � . <br />T CONTRACTOR ADDRESS Z PHONE / Z� <br />R INSURER G LIC S ,�-70 CLASS <br />C FIRE DISTRICT A -I (L O+J <br />T 40RK. COMP.N <br />RLA80RA70RY NAME Com- PERMIT S <br />SAMPLING FIRM PHONE S <br />IIIIIIIIIIIAUIIIIIIIIIIIIIIIII — <br />IAUK ID ar vxoxE Y <br />39- -L _ TANK SIZE <br />T 39- �L 1�-Z _ o CD CHEMICALS STORED CURRENTLY/PREVIOUSLY <br />A 39- 17 <br />DATE UST INSTALLED <br />�l Z_ a NLh <br />N 39- 000 <br />K 39- <br />39- <br />39- <br />P <br />9 -39-39- <br />P IIII _ <br />�j7�—� <br />L <br />A � APPROVED APPROVED WITH CONDITION(S) <br />N PLAN REVIEWERS NAME ATTACHMENT WITH CONDITIONS) DISAPPROVED <br />IIII 1111111111111111 <br />DATE -S� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDµCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LA <br />VS'IµID RULES AND REGULATIONS OF <br />THE PERSµ JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER lilt LICENSED <br />SUBJECTfTOWORMANCE OF THE WORK FOR WNION THIS PERMIT IS ISSUED,D AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: <br />"1 CER7(FyKER S MXSpENSATIg1 LAWS OF CALIFORNIA.. I SCALL NOT EMPLOY µY PERSON IN "1 CERTIFY THAT IN <br />TRA 1N THE PERFORMANCE OF THE TRACTOR'S MIRING OR SUBCONTRACTING SIGNATURE CERTIFIES NER AS OTHE CFOLLOWING. <br />COMPENSATlow LAWS Of CALIfOR IA ■ WORK FOR WNIC9 THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />APPLICANT'S SIGNATURE; I I' I I ,, <br />TITLE �C/v Nj w'/?D <br />DATE l <br />C✓.'fti �m ot. oos O ©6 '� a ,z. <br />-4s, <br />EH 23 046 (Revised 7/10/92) ///y �p S Co vl'P'yl � ✓e�� ne Y. <br />s" k-, Sa ?eo�3 r14 ✓L Sa,�wli `1 rc/, <br />so tj,s "Ll <br />y <br />P ICL �000 �tl 0af5 C. <br />