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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/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 />xREMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EN i3 046 (Revised 7/10/92) <br />SCmpIGs <br />Page 3 <br />-, , G <br />np^GV,r-cj 4L' <br />EPA SITE / Ca L oofotBOa9 <br />PROJECT CONTACT A TELEPHONE / LeO A D Cofsp - ZO -q4U 6/2--4 <br />F <br />A <br />FACILITY NAME <br />� <br />PHONE / _ <br />I <br />ADDRESS <br />4500E E . F mom -r CA q Qf <br />L <br />1 <br />CROSS STREET <br />T <br />Y <br />OWNER/OPERATOR <br />0 u G <br />PHONE 0 ^ `/ <br />o /U T <br />C <br />CONTRACTOR NAME\� Ck- / G _ <br />PHONE 0 .� _n/�8 _ 2-40 <br />N <br />T <br />CONTRACTOR ADDRESS 2735 Ta�SEE -bR_ C7E. E <br />J <br />CA LIC R 41405 I <br />CLASS '�1_'� �AZ <br />A <br />INSURER <br />WORK.COMP.p Zqo i 7 -9 Z <br />C <br />FIRE DISTRICT <br />PERMIT R <br />T <br />0 <br />LABORATORY NAME' EOLOC I CA L A�IDI I <br />0PxoNE 20q_ 9 56 CJ <br />R <br />_ <br />/� <br />SAMPLING FIRM (f)AME AS A VE) PHONE R 1' <br />I I I 111111111111111111111111111 <br />TANK ID RTANK 512E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />I <br />39- 7/ — SCYj C'7AL hiESEL FULL <br />T <br />39- 7� -Z <br />" <br />,F gi�Fl G/k-,po> INe <br />A <br />39- 7/ - 3 <br />' <br />n <br />o <br />N <br />39- 7/ <br />h <br />n <br />K <br />39- <br />39- <br />39- <br />II11 f1TiiiiTTfiTi fTTiT <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />_ <br />A IS ii 7 iH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE C�) - '%- 9 3 <br />IIIII111111111111111 Tii1i lii1T11TT11iiiTTiiiTTiiTiiiT111111 <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 THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />Q <br />APPLICANT'S SIGNATURE: TITLE 0C.UJ7 P y' DATEo—�S/-9T <br />EN i3 046 (Revised 7/10/92) <br />SCmpIGs <br />Page 3 <br />-, , G <br />np^GV,r-cj 4L' <br />