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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSIRE 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 />Y REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />- POp KS TD MSC e)1�7 <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE # GA Gig 5 1 V <br />I <br />PROJECT CONTACT i TELEPHONE" �Clt1n �1C7 9 33-o`0 7 <br />F <br />FACILITY NAMEJ�SC eo <br />PHONE # <br />ADDRESS � � 1 eJI�v" N1 CILJL.I �etUL STS -KI o\3 <br />I <br />L <br />CROSS STREET <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />I SNL-tL G71L vt <br />O ) <br />C <br />CONTRACTOR NAME I���, NIC FIYV CQxj�t'"I(J��L11�y1_ <br />PHONE S� Z <br />0 <br />N <br />LIC # %a �-L 1 <br />CONTRACTOR ADDRESS j-rX(R#4XX�!✓ Co <br />CLASS <br />�LI✓eei <br />T <br />R <br />rC <br />INSURER S N � 7 )� <br />VORK.COMP.# S7I' I `� - <br />A <br />C <br />FIRE DISTRICT CI Q� <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME 5t, UO1 _ (_ u GGHN = 1 <br />PHONE 1(e) 4GZ1 q6 0c)R <br />SAMPLING FIRM �llG jQ��o LtJ ��jT =�,�._, CDg,Lk� PL)(-j(�N PHONE M16 (6z-ZII0 <br />IIIIIIIIIIillllllfiil�llllllll <br />TANK ID # TANK SIZE CHEMICAL S STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- C�R+f —' - L) + <br />T <br />39- <br />O O <br />>7 <br />C) . r -A -ow <br />A <br />39- <br />NP.i^ S <br />UN K.vO��AI <br />N <br />39- <br />K <br />39- <br />39- <br />P <br />L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />I[IIIIII III III IIIIII 11111 <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 "K FOR WHICH THIS PERMIT IS ISSUED, I SHALL MPLOY PERSONSANUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." _. <br />DATE <br />APPLICANT'S SIGNATURE: TITLE <br />- POp KS TD MSC e)1�7 <br />EH 23 046 (Revised 4/26/94) Page 3 <br />