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1• i <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 />-L REMOVAL _ TEMPORARY CLOSURE CLOSURE IN Pi ArF <br />�f�j Cmd�t/ ���✓` <br />EH 23 046 (Revised 7/10/92) <br />EPA SITE M l �l �� 22� <br />C� <br />PROJECT CONTACT i TELEPHONE/ e(L pj QQ _ -713 <br />F <br />A <br />FACILITY NAME M G ' <br />PHONE *LTJ ���tD <br />3q <br />T ^ <br />ADDRESS A 23 1 S' S IiJC.jL IDf�J �� IJ L3J &(O <br />L <br />I <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />PHONE K <br />Y <br />" - -Z <br />�13•cc,a4--+,7 o <br />C <br />O <br />CONTRACTOR NAME <br />c..�F_ \ I SNS(. <br />PHONE M 2,f, -C(- <br />TCONTRACTOR <br />ADDRESS 2 �/�-12�/IFa.\.) cr <br />CA LIC K .�'l�cl-7� <br />CLASS 7i} <br />R <br />A <br />INSURER <br />p(�, �. ,4-12 Ot) <br />WORK.CCMP.O lJJG 5c40,Z S <br />C <br />FIRE DISTRICT ��, v^ <br />PERMIT M <br />BORATORY NAME, S , <br />PHONE Y <br />fR <br />�TMPLING FIRM PHONE / _ I-2• <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />o Q <br />/�- 4,z -UN kNt71Ne cam- <br />t 4 - <br />OOb <br />yam_ <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P IIII <br />L,y <br />APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />AEE <br />A KENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />IIIIIIIIIIIIIIIIIIII IIIII <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: "1 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br />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: �U--- --- TITLE DATE wl3a <br />�f�j Cmd�t/ ���✓` <br />EH 23 046 (Revised 7/10/92) <br />Page 3 <br />