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oln <br />films <br />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 />X REMOVAL _ TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />EPA SITE k C.. -'4C O� 23 PROJECT CONTACT 6 TELEPHONE K <br />F <br />FACILITY NAME �- <br />PHONE M YGC�-S6Z l <br />A <br />ADDRESS (�(' �� �O� Ave AGI <br />L <br />CROSS STREET S ZO <br />V/Q <br />1 <br />T <br />OWNER/OPERATORPHONE <br />0 <br />Y <br />/� /U N <br />C <br />CONTRACTOR NAME r'L �' 11 ( � yG <br />PHONE K <br />_ <br />N <br />/ T�-U <br />CONTRACTOR ADDRESS 22365 L2� <br />CA LIC k � 8^�" <br />CLASS <br />! VG! - <br />/ I <br />T <br />R <br />INSURER O� <br />WORK.COMP.M <br />A <br />C <br />! <br />FIRE DISTRICT C `T C%/� OG/,•— <br />PERMIT M <br />0 <br />LABORATORY NAME 5herwv0d <br />PHONE r A26 2 _5'Z5 <br />J <br />R <br />SAMPLING FIRM PHONE M <br />1111111111 <br />TANK 111111111111111 <br />TANK !D R TAN1j 512E I CHEMI[[qgLLB STqq,R ED CURRENTLY/PREVIOUSLY DATE UST INSTALL <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />1111 ff T ffllTiTlTfffiil1111TT <br />P <br />L APPROVED CONDITION <br />(S) WITH CONDITIOS) DISAPPROVED <br />_ <br />A ATTACHMENT WITH CONDITIONS) <br />G`� Z <br />N PLAN REVIEWERS NAME DATE — <br />11111111111111111111 fiii 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: "I 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 1N 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: ��� TITLE DATE /9,3 <br />EH 23 046 (Revised 7/10/92) Page 3 <br />