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P <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UWDERGRCUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERKANENT/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 # C/� O O q� PROJECT CONTACT i TELEPHONE # <br /> F FACILITY NAME�`1 I JONA NcH 9 <br /> A - 07,� <br /> TRAc _ <br /> C ADDRESS PHONE # <br /> 1 1OZ ZA.vr LN i2oA(J <br /> CROSS STREET A2.LUF <br /> T OWNER/OPERATOR <br /> Y 11 f- PHONE # <br /> O <br /> C CONTRACTOR NAME <br /> 0 !/ v,rL`i21/ t�(f - PHONE <br /> N CONTRACTOR ADDRESSS // <br /> T �9G� C(-L V.zea) G LIC # CLASS <br /> A INSURER in - I✓y 0 .B II9Z/,f// <br /> 4 I6 D WORK.COMP.# <br /> C FIRE DISTRICT .QC <br /> T PERMIT # yVw <br /> R <br /> - 0 LABORATORY NAME � <br /> r ARE Z GNn.IA[ E #sed / <br /> SAMPLING FM PHONC <br /> II1111111111111111111111111111 ENW� A PHONE # �5_� <br /> ANK I TANK SIZE <br /> 39- — (7j O CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST�INSTALLED <br /> A 39- — mo -' NBIL�U rJiv 4'wep,,, <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P nn <br /> L <br /> A APPROVED -_ APPROVED WITH CONDITION(S) -_ DISAPPROVED <br /> L > (SEE ATTAC MT WITH CONDITIONS) / ''77 <br /> N PLAN REVIEWERS NAME <br /> .... " DA —L� <br /> IIIIIIilllllllliLITE !/TE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIM COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN 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 CALIFORN <br /> APPLICANT'S SIGNATURE- / �Yi'.iJyl TITLE 65,L),-A) F— DATE D 7d ? <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />