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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 /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE IT p139 PROJECT CONTACT i TELEPHONE 0 �u Twod 4A-go7,3, <br /> F FACILITY NAME PHONE 0 �77 3!� <br /> A <br /> C ADDRESS <br /> 11,495— f n <br /> I Sao <br /> L CROSS STREET �� <br /> 1 <br /> T OWNER/OPERATOR PHONE 9 <br /> Y <br /> C CONTRACTOR NAME PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS /� � � CA LIL M L' CLASS <br /> T WORK.COMP.# IDwCa( i�la'o�>+ <br /> R INSURER NAICt — .P <br /> A PERMIT N <br /> C FIRE DISTRICT <br /> 0 LABORATORY NAME OO PHONE S <br /> R SAMPLING FIRM PHONE B <br /> TANK ID'M TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- Ilh <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> II11 I T fTFMffnT T(T(ffTf <br /> P <br /> ' L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> t l l l l 11 f 111111 I I I111 iiiiTtiliiTtiTlTfifiTiTTTifTfi 11111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 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, 1 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.-.. �-]' q p <br /> APPLICANT'S SIGNATURE: zf:- , / '1"'�' TITLE C. F U DATE , tN I <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />