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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 /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE 0 PROJECT CONTACT i TELEPHONE 0 Ca-rj� V4\10V\ 91(0 3(0$ OW9 <br /> F FACILITY NAME Ir-SA?C RQATo TravlsvIm"er PHONE 0 Zo9 94<3 SS(oq <br /> A ,\ � <br /> C ADDRESS CKAV�IK W0. <br /> i <br /> L CROSS STREET %E.l L l-avle-- <br /> 1 <br /> T OWNER/OPERATOR 7'cderal Evveryv(ay me kcty wr Ayv(ca{ PHONE N <br /> Y 7-02 (o4(o 30(o1 <br /> C CONTRACTOR NAME See CDVer lege,, •:p}eM PHONE 0 <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC 0 CLASS <br /> T <br /> R INSURER WORK.COMP.O <br /> S ,,1I q <br /> C FIRE DISTRICT Ci 0 S`-p G��VV �IrC �IS IC- S6C�l C4,11 PERMIT 0 <br /> T <br /> 0 LABORATORY NAME WODav-%Q A -C( de_ �Ftderal Seru(eas CWGFS PHONE 0 <br /> R <br /> SAMPLING FIRM PNONE 0 91(p 3coT ocl <br /> TANK 1D 0 TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39• N OMZ 1000 5(Q«0 dleset Fuel G1rca 14(04 <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 11 <br /> TI TTf ITT <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIDNS) <br /> N PLAN REVIEWERS NAME DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATUF.E CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICR THIS PERMIT 1S 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 /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WRICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WDRKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: TITLE DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />