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L <br /> ENV ONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> AF`PLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERM` ENTrTEMPORARY C_OSURE OR AEANDONMENT IN PLACE CF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIR S 150 DAYS=ROM THE APPROVAL CATE CO NOT WRITE IN ANY SHADED AREAS, INDICATE PERMIT TYPE: <br /> X REMO L O TEMPORARY CLOSURE O CLOSURE IN PLACE <br /> CAS 0;r co FACILITY INFORMATION <br /> PROJECT CONTACT1 J PHONES ZC�7 • `Sly°" <br /> FAC > t' s PHONE#" _ ,Sr <br /> ADDRESS 2 r` <br /> CROSS STREET <br /> CWNER OPEP.P.-OR 1 - PHONE# iAa <br /> CONTRACTOR INFORMATION <br /> !.TRACTOR NAM z - 1 v. PHONE# 53U'87 Y <br /> CONTRACTOR ADORES .0, x .C CA"IC <br /> # CLASS HZ <br /> INSURER '•� WORKERCOMP* �S i <br /> FIRE DISTRICT PERMIT <br /> # W <br /> LA80RATORY NAR'L K i vl I COUNTY PHONE <br /> SAMPLING FI4M L - PHONE# f _ <br /> TANK INFORMATION <br /> !PRESENT AN7 FAST I OATEINSTALLED <br /> 39- <br /> �. 39- <br /> 39 <br /> 6 <br /> 3 ELVS `_-Rd' LAWS.AND RULES AND <br /> .:IGWTURE CERTIFIES THE <br /> L _ - - _ _ - _ :-_OY ANY PERSON IN SUCH <br /> 1i3 OR SUBCONTRACTING <br /> S,.'Y- _ . <br /> H.' PERMIT IS ISSUED, i SHALL <br /> EMPLOY PFR SONS SUB,EC'T V. RKERS <br /> APPLICANTS SIGNATURE t`' �-�'+��^ _ TITLE o�+t'V�cs : V DATE <br /> 0 APPROVED MAPPROVED WITH CONDITION(S) El DISAPPROVED <br /> (SEE CONDITIONS BE.CW AND�OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM ) TN/i-`. i?A— DATE d3l 1A <br /> ANY DEVIATIONS F M THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK, <br /> CONDITIONS: <br /> EH 23 046 (Revised, - :.. . . 3 <br /> L <br />