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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 CLOSURE IN PLACE <br /> EPA SITE # OO PROJECT CONTACT & TELEPHONE # W <br /> F FACILITY NAME I P E # <br /> A <br /> C ADDRESS ' <br /> I <br /> L CROSS STREET Zl7 <br /> I <br /> T OWNER/OPERATOR PHONE # pp <br /> Y 'O S <br /> C CONTRACTOR NAME �3 Lsgwu <br /> _ PHON # - <br /> 0 1,' <br /> N CONTRACTOR ADDRESS 'Owl CA LIC # CLASS <br /> T <br /> RA INSURER WORK.COMP.#EtJ, ,bq q-O <br /> C FIRE DISTRICT PERMIT # ) <br /> T IV <br /> 0 LABORATORY NAME COUNTY ���'- PHONE # - O O <br /> R <br /> SAMPLING FIRM p AAcit � C G&J4o''-zm yes 'Zy�C, PHONE # p�„0Q_Srla-Oleo <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- - �O _ CwQ ---iaa <br /> T 39- - ;pss. <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( EE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N �d <br /> PLAN REVIEWER'S NAME `�/I�TI.ET/Er 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: "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 THATIN THE PERF NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFO N A. <br /> I � pp <br /> APPLICANT'S SIGNATURE: f TITLE Pc'� 6:A �n� DATE <br /> CONDITION(S): (f /r'1 V5i ' <br /> Z� 7D TaC4" r�� Sorc.�.�G4s/�j or�7 /�4CyE tvEgo� <br /> 1/94 i�/� �IoL To �1rG41r9rLrl� <br /> -jp 4716: pk$4.9� , ,a oma- A66&--F- ,e�: �.s.,_ -c <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />