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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PUCE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AHAZAR OUST CUTE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE __ CLOSURE IN PLACE <br /> PA <br /> C'^ 0 A 17 / PROJECT CONTACT d TELEPHONE # <br /> ME��'iI I -jO)N NCH iZ0 - ' O7$B <br /> TA i c _ PHONE # - ,3 - i R.v7" LAI/ k0,4eQ G,T TOR <br /> Y C 0� PHONE # <br /> v�xMA - Zo <br /> C CONTRACTOR NAME N� NT <br /> 0 � (/ j'� PHONE # zd4-�33-o7r� <br /> T CONTRACTOR ADDRESS /pG� i/�� u�E� w� CA LIC # CLASS <br /> ,4 <br /> INSURER - AJ 25 - o A <br /> w hL o WORK.CCMP.# L y—tel <br /> C FIRE DISTRICT AG <br /> T PERMIT # NA� <br /> 0 LABORATORY NAME Z <br /> R T AQ E IankJL PHONE # <br /> SAMPL)NG FIRM GN(r <br /> Y iIIlliistitiiiiiiiifililltllll � %,� PNCaE # Zo4-8 <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST NSTALLED <br /> 39- / O a1— O� �..,.,. <br /> T 39-i zvwu— )G q c --' 1eti114 <br /> rJ�v�.riuJ„ <br /> A 39- SbO w 1 AU <br /> gwW <br /> N 39- <br /> K 39- /�s <br /> 39- <br /> 39- <br /> P ffffffffffffffffffffffw <br /> ILII <br /> L APPROVED _ APPROVED YITN CONDITION(S) DISAPPROVED <br /> N PLAN REVIEWERS NAME 1�/ CSEE ATT T KITH CONDITIONS) <br /> I1111111111111I V I I I DATE <br /> 11111III <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAM 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 NARK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORN 4\IIA lI� . <br /> APPLICANT'S SIGNATURE: I.AT•'M / T✓fiJ�rl� TITLE PrL LL,Ij)f/✓ DATE 020 ?L <br /> i _ <br /> V <br /> i <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />