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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- _ CLOSIURE IN PLACE ' <br /> fEPA SITE # -A17 PROJECT CONTACT i TELEPHONE # 464 AAAILTm(N (2rg1 i;;zq, 5-!, <br /> F FACILITY NAME ,/ (t_R (� PHONE # �i �Z- <br /> ADDRESS �'(S�6 9, 1j 152,11 ` I <br /> CROSS $TRE ET g <br /> 1 <br /> t OUNE•3/gpkIRATOR PHONE # <br /> C I CONTRACTOR NAME SiiI77PHONE # 25:7f ,szf/ 9653 <br /> vCCNTRACTOR ADDRESS /y/3 Sc>;.f-TN CJ cA LIc # Iteo l5/ CLASs.51//3, C6//OXo <br /> .R INSURER �i OLDE9 �746b� _rA1UoAAI( -' �/� L'ORK.CCMP.# 4//G t[1sl(q _X <br /> ! ^ F!RE DISTRICT / JoA (q &-1P4mtff LAM `ST- <br /> PERMIT # <br /> t <br /> ' 'A&CRATCRY NAME PHONE # Za9 S�L d9o0 <br /> $AMP!!NG FIRM �'O /Ii?�•LI7��'C �iq'l3O2/J �lZ/SS PHONE # 2419L 09a0 <br /> I I I 111111111111111111111111111 <br /> TANK 10 CH,F�MICAL.s�S�Jj,&REO CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39• l©. PTD Cod Q. /�Ye C <br /> 39- <br /> 39- <br /> � � 39• <br /> < 39• <br /> 39- <br /> 111111 I I i f 111111 1 1111111 I I I III ill l 1111 I 11 I I I I III I I I I I I I I I 111 111 ! 1 11 <br /> P <br /> � ( APPROVED APPROVED WITH CONO ITfON(S) DISAPPROVED <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> .N PLAN REVIEWERS NAME DATE <br /> 1111�i 11111111111111 11111 <br /> I <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: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF TXE WORK FOR W ICH THIS PERMIT IS ISSUED, I SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAW <br /> OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCW!NC: <br /> "i CERTIFY THAT IN THE PERFORM CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SMALL EMPLOY PERSONS SUBJECT TO LORKER'S <br /> j CCMPE.NSATICN LAWS OF CA FOR <br /> A." <br /> APPL!CANT'S SIGNATURE: ✓""�V "- TITLE l�'�� DATE <br /> i <br /> _+ 23 0:6 (Revised 7/10/92) Page 3 <br /> i <br />