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� J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNOERGRCIJNO STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZAROCUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> V REMOVAL TEMPCRARY CLOSURE _ CLOSURE IN PLACE <br /> V EPA SITE x �� PROJECT CONTACT L TELEPHONE x �(e* j+kMlL-Tt7ll <br /> F FACILITY NAME 1i�.(.l<7 PHONE x C�9)�s3�— Z b'' <br /> li'�Lc; �I-F i t(;�r� <br /> I : Aooa.SS 3�ZUt7 S . e14K-IS AA1 b - �c �A '( 7G <br /> L CROSS SIRE.T <br /> f OWNER/OPERATOR PHONE x <br /> T CONTRACTOR NAME PHONE x 4j, �5! g6S3 <br /> CCNTRACTCR ADDRESS /Z/? SrX•TN Fm 0,14e5To, e CA LIC $ 5��986� CLASS4/,,S, <br /> R INSURER C Ci-ovl (5#6L9- Tx�MAI( 20, WORK.CCMP.x�Q�G L`�SlC�3-Gl'J <br /> FIRE DISTRICT fi L?ui J coV I PERMIT x <br /> 'ASCRATCRY NAME6'eoArvA��1T/Cf]-L /L�y.�OLg70.P�gf PHONE x Z,j f .577Z6 fOo <br /> SA.YP'_!NG FIRM G'�E''D ti?G %7ICy-C, 6f-50a ] 7lf,P/SS PHONE x [Q9 J�L Poo <br /> I 11111111111111111111111111111 <br /> ?] <br /> TANX TANK S ZE CHEMICALS STORED CURRENTLY/PREVICUSLY ATE UST INSiAV <br /> 39- 5 S"� - f Gal'O"l JL D(JN.✓l/J of IL <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> Illllllil III11111111111111111 )1► Ili III► 11111►11 11 I1 II II II►i 1111 11 ►II►II 1111►11111 ►11111 I—l—illllllllllli <br /> APPROV APPROVED WITH CORD IT(OX(S) DISAPPROVED <br /> ( ATTACHMENT WITH CONDITIONS) ' <br /> a PLAN REVIEWERS NAME SEE GATE <br /> 11111111111111illill 11111 <br /> APPLICANT MUST PERFCRM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS CF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IX <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 WCRKER'S CCMPENSATIOM LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWINC: <br /> "i CERTIFY THAT IN THE PERFOR NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SMALL EMPLOY PERSONS SUBJECT TO CORKER'S <br /> CCMPENSATICN LAWS OF CA OR A." <br /> APPL!CANT'S SIGNATURE: TITLE DATE <br /> °.+ 23 046 (Revised 7/10/92) Page 3 <br />