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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 y0 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOVZ RQ -w— _ REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE EH 23 046 (Revised 7/10/92) Pepe 3 EPA SITE Y N / -, PROJECT CONTACT i TELEPHONE Y F A FACILITY NAME W4LZ Yom/ PHONE Y 11b6 d�3� C 1 ADDRESS 1401 f✓ . �C,PL�"/I�IO.�>T� Sji7 GiCl17.c.� e;O L I CROSS STREET v 1<114-t/ YOWNER/OPERATORcr PHONE Y C CONTRACTOR NAME-rNrE6✓?irY %/� T.7?c//CASs PHONE Y 0 N CONTRACTOR ADDRESS ILO$ /j/0,P0e--eGZT7-- STIciF G LIG Y CLASS T R INSURER COM C O WORK.COMP.Y A C FIRE DISTRICT N� PERMIT Y T 0 LABORATORY MAKE N �/} PHONE Y R SAMPLING FIRM N PHONE Y IIIIIIIII111111111111111 111 TANNK ID Y TANK SIZE CHEMICALS SPORED CURRENTLYlPREVIOUSLT DAT �1 IJ)LSTAlLE0 T 39- � Z'�� / do U b�Fda 4-',�< 1 39- �T7 -02 - LO o v b/tdoUtic---6� A 39- N 39- K 39- 39- 39- FfliiilTTITTiT P IIII L PROVED AP WED ITN CONDITIONS) _ DISAPPROVED A /7 �, A WITH CONDITIONS) '7„y� I'✓�- L / N PLAN REVIEWERS NAME Lv DATE 11111111111111111111 11111 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: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA. - APPLICANT'S SIGNATURE: !W TITLE A -416/Z- DATE EH 23 046 (Revised 7/10/92) Pepe 3