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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 />V/ REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE # 1. W�� <br />d oe ( <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY NAME <br />!�` ✓ - PHONE #,�_ p A <br />A <br />C <br />ADDRESS <br />U6134 <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR//may <br />/fin <br />DIV161V'F1 <br />PHONE # <br />Y <br />ya <br />�1/OIkG <br />C <br />CONTRACTOR NAME <br />rlq6,7 / <br />PHONE #,. j/ ff7a - <br />/� <br />N <br />CONTRACTOR ADDRESS �O <br />CA LIC # 3/D <br />CLASS <br />I <br />R <br />INSURER <br />WORK.COMP.# " /tr <br />A <br />C <br />FIRE DISTRICT <br />i ✓ <br />PERMIT # <br />0 <br />LABORATORY NAME <br />PHONE # %)-753- 9AJ-roD <br />R <br />SAMPLING FIRM uIC�PHONE # <br />IiI1111111777 <br />TANK ID # <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- A W- <br />VL <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />1111 <br />T <br />P <br />L <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A <br />_ <br />S ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />II!!IIII1lII11111111 <br />J DATE =' <br />IIIIIIiIHII111111111111111I <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 <br />SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 141 CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK <br />FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT <br />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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />SIGNATURE: <br />" TITLE [/. i.-��/e'(0�% DATE <br />APPLICANT'S <br />=/ <br />y"-�%l <br />EH 23 046 (Revised 7/10/92) Page 3 <br />