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NOW v0 , - S/z3o 33 ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE EPA SITE # d.,17L Q d DO p}&A6, PROJECT CONTACT 8 TELEPXouE yy F FACILITY NAME PHONE # A CI ADDRESS 2q (n T L CROSS STREET 1 I PHONE # T OWNER/OPERATOR d - Y Sl C CONTRACTOR NAME G/1/C.LJ - PHONE # 0 N CONTRACTOR ADDRESS CA UC # .Cf o-L/O CLASS 13 G T /— R INSURER WORK.COMP.# A_/J 7 A I /(/ C °IRE DISTRICT PERMIT # 0 LABORATORY NAME R SAMPLING FIRM PRONE # IIIIIIIIIIIIIIIIIII1 1111 1 TANK ID # TANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST 3NSTA L 39/ o u Conte ' �'"✓ -� T 391 -2 Oc'7 Cn•,t••w'.n..c _ _ N 39y - e 39- 39- 39- 11111111111111111111111111111 11111 111111 i t 1111111 II I I I III I I I I I I I I I I I I I I I IM111111111111111111111 x APPROVED APP VED WITH CONDITION(S) DISAPPROVED SEE ATT HMENT WITH C [i]ONS) , / ? V PLAN REVIEWERS NAME DATE J 11111111111111111111 I i l l l APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A IMNNER AS TO BECOME ! SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." y� APPLICANT'S SICNATU" TITLEDATE a� �+ I i S 1 e Je PR rn� J20S2 Co 1-W Page 3 EH 23 046 (Revised 7/10/92)