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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 FROMTHE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />)C REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />T <br />EPA SITE #�<fcoo GQ <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY SANE L% �� ( <br />PHONE # -Q <br />A <br />C <br />J <br />ADDRESSl l�a <br />G <br />I <br />LCROSS <br />STREET 0 r c— ToISI zU� <br />I <br />T <br />OWNER/OPERATOR <br />C o<� <br />PHONE # <br />Y <br />�/ <br />C <br />CONTRACTOR NAME dU — �H PHONE <br />N <br />CONTRACTOR ADDRESS S G T� �d a LIC # gG63S2 CLASS <br />R <br />TCo <br />INSURER ov Zr�sa s I <br />WORK.COMP.# <br />155 f�1 - 4 <br />A <br />C <br />FIRE DISTRICT "�`' d fC )/'��g h-j� <br />PERMIT # <br />0 <br />LABORATORY NAME j e �/ <br />PHONE # 6G-%-SZS6 <br />R <br />SAMPLING FIRM PHONE # <br />illllllllllliiilllllllllllll <br />TANK 10 #TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- , ,- L-./)OOOm/ <br />T <br />39- <br />A <br />39- <br />/ <br />N <br />39- <br />K <br />39- <br />39- <br />IIII T <br />P <br />L APPR D PPROVED WITH CONDITION(S) DISAPPROVED <br />A TTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS MAKE DATE <br />1 1 1 1 1 1 11111111111111 I I I I I <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACAJIN 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.- <br />�/ <br />APPLICANT'S SIGNATURE:/ J� TITLE //�42 e/� DATE l� <br />EH 23 046 (Revised 7/10/92) Page 3 <br />