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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />LICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />'HIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE #� q5j 3', <br />PROJECT CONTACT i TELEPHONE # , <br />� •�� ')-oO v6 �s I <br />FACILITY NAME NEW R S• , r + ', ,� <br />PHONE # I� S -2s l <br />ADDRESS 8co QST <br />CROSS STREET <br />OWNER/OPERATOR <br />PHONE # <br />X09) <br />���-sass <br />' <br />^T <br />CONTRACTOR NAME 2t SN c� 1 NAQL'Er'e S .LN c- <br />PHONE # <br />S/O Z <br />N <br />T, <br />CONTRACTOR ADDRESS 1 3 <br />CA LIC # 4 24 7 6 <br />CLASS Az CS7 <br />A <br />INSURER L C� �RMIr S <br />WORK. COMP.# WC- SRI 66 q8 <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />F <br />LABORATORY NAME J' o -A �+ <br />. uA ` <br />PHONE # �1l a <br />�6 - 6o <br />SAMPLING FIRM '� N --- D Ra eS '." PHONE # <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />2Scr� qr <br />6 Fye.lT"�-- <br />A <br />39- <br />rl f, rue.( •. 1 <br />>. <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P II11 m <br />L APPROVED R YEK ITION(S) _ DISAPPROVED - <br />A S ( E TA T,� CONDITIp15) <br />i } <br />N PLAN REVIEWERS NAME /� <br />DATE <br />11111111111111111111 11111 <br />APPLICANT MUST FEKrORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIY COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN CCUNTY 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 IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.- <br />-� /�' <br />APPLICANT'S SIGNATURE: \ "'W..��C _ L\X.�I n 1/-LcCh. o� TiTIEodc DATE Ty793 <br />C�j ` SCTL O Cl AA"I F- S yll Y LN'\ k\- <br />EN 23 046 (Revised 7/10/92) Page 3 <br />COti We�+-- WA`1 <br />