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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR <br /> ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <br /> THIS PERMIT EXPIRES 90 DAYS/FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> y REMOVAL TEMPORARY CLOSURE ABANDONMENT' IN PLACE <br /> ii <br /> EPA SITE # Cr7c. QQD(p��D�D PROJECT CONTACT 8 TELEPHONE <br /> ,'# 1�44 IC g <br /> j <br /> F FACILITY NAME ��/{/� �+!��,,� � <br /> A \ l PoN (� lC- �i/�R+LJ ��r fL II [PHONE #20?, <br /> C ADDRESS 2� I /� <br /> I 7 1t� <br /> L CROSS STREET fd gS7 1&41N <br /> 1N z c— <br /> I <br /> T OWNER/OPERATOR <br /> i{ PHONE # <br /> Y tpoN u�llFi�lJ <br /> "OL- <br /> 5 TRI CT 209, 57947, 2/3 <br /> C CONTRACTOR NAME �I'o PHONE # <br /> 0 <br /> �1 <br /> i N CONTRACTOR ADDRESS L{?� (jHyl y CA LIC #1r (�!i�r CLASS/1 / r <br /> T V J T Z r7- —W <br /> R INSURERC&[N WORK.COFIP.# g67{C a <br /> A I <br /> C FIRE DISTRICT r'r 04- el&IV iI PERMIT # <br /> 0 LABORATORY NAME �? �' PHONE #�ORN�G�(TrC.,�}c. �i 26�'S Z , 0900 <br /> R <br /> SAMPLING FIRM �EoRNp�c��r � PHONE # �Cf, S�z DGj p <br /> NIIIIIIIIIIIIIll1lI1II1IIII1! ,} cc ! <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- Lb G -OAJ bG I;ti <br /> T 39- 1} <br /> A 39- if <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- a <br /> P IIIIIIIII1I11IIlII11111I1II1lI IlI 11111lIIII111III11II111I11l IlIIII111111IIII111111lII1l111111111111 I1II1IlIIIIIIIIIUIII <br /> L APPROVED APPROVED KITH CONDITIONS) I? _ DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME I DATE O p <br /> lffliz _ <br /> Ill Hill 111111111111Il11I11I1I1111iI1Hill 111 111llIIIIII111IIIIIIlI111111i11i11lI II11I1l1ilIIIlIIIIIIIIIIIIIII11Ill 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES; STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOiAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WiICH 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 FOLLOWIN <br /> 111 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." 1'h <br /> APPLICANT'S SIGNATURE: TITLE S�l�f?ftT�/T_ DATE <br /> t <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />