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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVLSION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL _ TEMPORARY CLOSURE -ZCLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME DURANGo TiR� cvii/.��i✓Y PHONE # y3 1j97Z7 <br /> A <br /> C ADDRESS Z 7{/!�C S EL 0000 T <br /> I T <br /> L CROSS STREET 10WE'L� ��/�/1/U� <br /> T OWNER/OPERATOR 1 PHONE # <br /> Y <br /> C CONTRACTOR NAME pj PHONE #J`rO-(oPJ��pZ/'1/ <br /> N CONTRACTOR ADDRESS Z� �T �iienvP JpUT`j CA LIC # AIX CLASS N <br /> R INSURER WORK.COMP.# <br /> :A. <br /> A '/1 <br /> C FIRE DISTRICT s�0.'J/ 70y� PERMIT P <br /> 0 LABORATORY NAME ,,e,,,co G/!V/%'DPW C�NTY�'� �S PHONE #,fid^�3Q <br /> R SAMPLING FIRM //✓ N YEB�/q/Y� �s`rlaG' PHONE #`�v 9 <br /> IIIIIIIIIIIIIIIIIIIIIIIIlillll <br /> TAN ID # TANK SIZZE� CHEM�tICALSTO <br /> SRED Suit Mit'//PREVIOUSLY DATE UST INSTALLED <br /> 39-74 Z3'�o'%0/ 1Q, bOrJ C7�/�.��/ //%PSP <br /> T 39- <br /> A 39- <br /> M 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N <br /> PLAN REVIEWER'S NAME DATE <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, 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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: IgA'1 �A/,�N�J �'7 TITLE ea.,,tGw- DATE <br /> CONDMON(S): <br /> EH 23 046 (Revised 7/10/96) Page 3 <br />