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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 AREAS. INDICATE PERMIT TYPE BELOV: <br />REMOVAL TEMPORARY CLOSURE __ CLOSURE IN PLACE <br />EPA SITE # PROJECT CONTACT i TELEPHONE # J <br />/ / /GmeS LESSIY1Gn Cri/6J68. <br />A FACILITY NAME eQt/7YQNS - .S-1oc&�n 14pVgi2rl0gcG 51 <br />,274 <br />PHONE #iZ09) rfAQ_ xWs, <br />C ADDRESS q;7( J f <br />I <br />CROSS STREET <br />T OWNER/OPERATOR <br />Y CA Ve�7 <br />C CONTRACTOR NAME/G <br />0 <br />N CONTRACTOR ADDRESS 9U`5T' <br />T 8G <br />R INSURER <br />A <br />C FIRE DISTRICT STQ F <br />T <br />O LABORATORY NAME S G r <br />SAMPLING FIRM Sq J! <br />TA������#��������� <br />i 39- <br />f 39- <br />39- <br />' 39- <br />39- <br />39- <br />I Mm 1111111111111111111 <br />ZrY-er i'1/ar / /6a�' 8 S7(reef <br />c! cWa <br />00r Fferlog 74 Cn irleer.:-� <br />/rrof Oa , <br />�^_S�i'Pef Sacro..ea.� C4 U LIC # <br />V e /rIGLL3/70 �� - <br />r eco -0(o <br />TANK SIZE <br />PHONE # <br />PHONE # <br />a c - G6 L Uy <br />sG CLASS <br />WORK. CO'!P.9 / Z3 / 00 6 <br />2GL - 96 <br />C . I PHONE # z - 8 <br />PHONE g? - 7 <br />CHEMICALS }TOREO CfRRENTLT/PREVIOU/SLY I DATE UST <br />APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />PUN REVIEWERS NAME (SEE ATTACHMENT WITH CONDITIONS) <br />-��������������I����� DATE <br />mmummmmun <br />ifill <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAM JOAOUIN 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, 1 SMALL 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 CALIFORNIA." <br />APPLICANT'S SIGNATURE: <br />23 O46 (Revised 7/10/92) <br />Page 3 <br />TITLE /// DATE 93 <br />