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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 FRCM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE ��11" <br /> "EPA SITE # 4#e0009'Z O PROJECT CONTACT i TELEPHONE 9 lZleg 14AA�rfbrOu CZFV �ZY/. Z' 3 <br /> 44?F FACILITY NAME OL rom vij ,t KQa 4AA19"-uatbs PHONE # i7iY— 3U <br /> A 'A <br /> C ADDRESS ZCbsf f, MILE, tool t' <br /> 1 <br /> L CROSS STREET Piet SDN Q6A-17 <br /> I <br /> r OWNER/OPERATOR PHONE # <br /> i T Ztog 923-1+1 <br /> C I CONTRACTOR NAME sjilf-7 PHONE # 4�l9 Vis! g6S,3 <br /> 0 <br /> 4 CONTRACTOR ADDRESS /Z/� Srx,TN �/'[ �eGeSrO, c" uc # S�Sr966S/ cuss y/fl, C6//OXo <br /> 2 INSURER I , YORK.COMP.# III6 tYSI� <br /> C FIRE DISI RIOT agp/ �Q/4q�(f,�/ (-jJC(fA.l�'�,(-jf'Qi /�(b IQA- PERMIT # <br /> r �7 <br /> '.A"eCRATCRY NAME Be�i//VgLyT/��}'L Lfr2�L97p,e/i=S PHONE # 01117 90o <br /> SAMPLING FIRM PHONE # zp9 - Z 094 <br /> 1111111111 <br /> TANK CHEMICALS111111111111111 <br /> TANK 10 TANK SIZE CHEMICALSSTORED CURRENTLY/PREVIOUSLY DATE UST IHSi _ <br /> 39. <br /> r 39- 1 sz o 7- <br /> 39- <br /> 39- <br /> K <br /> 39- <br /> 39- <br /> 3 39- <br /> 39- <br /> 111111111111111111111 1111111 III III 1111 11111 III 11 I III 1 11 IIIII II 111111 1111111 II 11111111 II 1 11111 <br /> I L _ APPROVED k APPROVED WITH CONOITION(S) _ DISAPPROVED <br /> A (SEE ATTR HMENT WITH CONDITIONS) <br /> 4 PLAN REVIEWERS NAME DATE 1 q <br /> Iilllilillllllllllil IIIII <br /> t <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LADS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT 14 <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 CCMPEXSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING'OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWINC- <br /> "i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO W'ORKER'S <br /> CCMPE4SATICN LAWS OF CALIFORN <br /> A?PL:CANT--'IIS SIGNATURE: <br /> yVl�" TITLE �'R, DATE <br /> W LL w 3 <br /> _:; 23 046 (Reviszd 7/1992i lS• Page 3 <br /> I <br />