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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 />Y REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # joj Ftw- Avoey-w,, (w) 82032-2-`i <br />F <br />FACILITY NAME SL)BV'I�BFF,,j 1�'LOI'�:L'NS <br />PHONE # aoq) 93:5 z1 1 S <br />A <br />C <br />ADDRESS 23gOI S- �H�-LSM �'1J P-0, <br />1 <br />L <br />CROSS STREET FrT.,T /l -r74 S7)2E-gT <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />;Lo0a0:V5300 <br />Y <br />SuGLL261YN PrweI}ljG= FFQW(O fl NESE <br />C <br />CONTRACTOR NAME ALS ENVI2ONMLT/-T-PILI INc <br />PHONE t(- 2-0 3 2- 21 <br />0 <br />N <br />�^A/ <br />CONTRACTOR ADDRESS 2(D �i1 C2DW (,ANyo&) J-, 5-1e S <br />CA LIC # <br />CLASS A <br />T <br />R <br />INSURER STAB F7QA]O <br />WORK.COMP.# I 531010 - qy <br />C <br />FIRE DISTRICTI1V,Ly - <br />PERMIT # q41002 -63T <br />0 <br />LABORATORY NAME' 27"o�T'1'Y" - -f6 <br />PHONE # <br />R <br />- <br />SAMPLING FIRM AciT� , _ PHONE <br />INSTALLED <br />TANK I TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DAT�� <br />�T <br />39- VA 0 <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />L APPROVEDROVED WITH CONDITIONS) DISAPPROVED <br />_ <br />�1 <br />A (SEE TTACHMENT WITH CONDIT ) //�/-% <br />N PLAN REVIEWERS NAME DATE (/ (� <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDI AN ES, 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 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF <br />\CALIFORNIA." <br />APPLICANT'S SIGNATURE"Z..., is TITLE/Li,4AJH66x. DATE 99./ <br />EH 23 046 (Revised 7/10/92) Page 3 <br />