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J� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <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 _ ABANDONMENT IN PLACE <br /> EPA SITE # /� /1 • C PROJECT CONTACT 8 TELEPHONE # <br /> l J <br /> F FACILITY NAME O <br /> A c PHONE #-CJyA ��� —� O <br /> fip- <br /> C ADDRESS _ <br /> I <br /> LCROSS STREET <br /> I <br /> T CWWER/OPERATOR PHONE # (,`L D tl Slog-S3il <br /> Y ora 12 <br /> C CONTRACTOR NAME PHONE # 001 <br /> 0 1 /Vl <br /> TCONTRACTOR ADDRESS o O J " I CLASS <br /> R INSURER O <br /> p NS K.COMP.# C^p x / <br /> rryAj CB 6 <br /> C FIRE DISTRICT C' 'gyp/,E <br /> T , - PERMIT # � bF- On <br /> O LABORATORY NAME <br /> R PHONE # <br /> SAMPLING FIRMntP Pon <br /> � PHONE # <br /> unununnn��t ul�i K-" <br /> TANK ID # TANK SIZE CHEMICALS STORED URRENTLY/PREVI SL DATE �T INSTALLED <br /> 39- /0� k ^/ <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P Iilllllllllilllllllllllllllllllllllllllllilllllllllllllllllllllllllllilllllllllllliilllllllllllllllllllllllllllllllillllll <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A �J J `��(SEE�ITTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME_ JWCI,t(./ �V(,/,t1b DATE /yl{/ <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIII IIIIIIIill11it111it111111111111111111111111111111it11111111111111111111111111111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN 40ACUIN 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: "1 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE M CT DATE 3 7 <br /> EH 23 D46 (Rev 2/8/97) ft Page 3 <br />