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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> 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 #GSL C50k Lk q LA S'�L-$ I PROJECT CONTACT & TELEPHONE # _ 3 <br /> F FACILITY NAME — PHONE # _ -,S915 <br /> A <br /> C ADDRESS S L <br /> I <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE # <br /> Y - - pnvc �� iSS 3 -85 5 <br /> C CONTRACTOR NAME �K O 'C� O Z U PHONE # 5 � - <br /> N CONTRACTOR ADDRESS �� CA L[C # CLASS <br /> T <br /> R INSURER WORK.COMP.# --is �(4 <br /> _ �` <br /> A e, L <br /> C FIRE DISTRICT PERMIT # <br /> 1 <br /> 0 LABORATORY NAME 1[.l1 <br /> utW� COUNTY CJ` PHONE # .530 _)_q 7- L{ LQ <br /> R <br /> SAMPLING FIRM 11LLL� NkXA t-\( �- PHONE <br /> I��1������� �11 <br /> TANK <br /> TANK ID # TANK' SIZE CHEMICALS STORED CURRENTLY/PREVI WSLY DATE UST INSTALLED <br /> 39- n <br /> T 39- f7 Ern I yAy Islaf�l'7 "'7l4 <br /> A 39- - <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED �pAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A � EE, NS BELOW AND/OR ON ATTACHMENT) <br /> N )/ <br /> PLAN REVIEWER'S NAME DATE <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, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALI NIA." ((((\\\\ <br /> APPLICANT'S SIGNATURE: (-D[L� f TITLE CAo, lQ-CYnd _ DATE C' <br /> CONDITION(S): <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />