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Nwwl <br /> EMVIRDNMENTAL 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 /> - REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # CI!-1 PROJECT CONTACT L TELEPHONE #�oH� LyA)eH 209- 833-07ST <br /> F FACILITY NAME ) AL T PHONE # �(09- �3S-( 700 <br /> A <br /> C ADDRESS yWE6T- ELEVENTH 5TRE IR c� 6 <br /> 1 <br /> L CROSS STREET <br /> I DAM A S T E I <br /> T OWNER/OPERATOR PHONE # <br /> 7 The C,1f` oF TRA(- nT M2 Mot, 1tEQMA 6 -L/y2 <br /> C CONTRACTOR NAME W =NJSRoN,-AI 1TA SGRUSL -CNC PHONE # <br /> 0 2-09 - 833-0-75-8 <br /> N CONTRACTOR ADDRESS 9 1 v � h CA LIC # �L'S O CLASS Nn z NA'T <br /> T J <br /> A INSURER N L <br /> STA �� M WORK.COMP.# Z 1-19 <br /> —Cl3 <br /> C FIRE DISTRICT T�A L PERMIT # N A <br /> T <br /> 0 LABORATORY NAME GK GN SR EfuT M1&fme MN ( PHONE #f10_ i/E3L1- <br /> R <br /> SAMPLING FIRM PHONE # <br /> IIIIIIillllllllllllllllilillll 'NRtt l- N z -075 <br /> TANK ID # V TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- - cellon FJEL N9SL 1JNICIJnwV <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIII <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / ' (SEE ATTAC WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111111111111 I i l l l <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM 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: "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 WANNER 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: TITLE ("REBID CA-r DATE /0 Z <br /> V <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />