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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PEP.Wr <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- 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE N PROJECT CONTACT d TELEPHONE •T -4-189 57 <br /> F FACILITY NAME K T PHONE 4� -1 <br /> a <br /> C ADDRESS <br /> IFa FSFA�IC 1 <br /> L CROSS STREET <br /> T OWNER/OPERATOR �y .I [�J! !11`.� PHONE LM 3-1-7 izB 3 <br /> Y U ��1ff 'lr1^\tE�y lVJ <br /> C CONTRACTOR NAMEDEL k, t 1 L. 'ki, PHONE X g7 -4-1 <br /> 0 i r f ` <br /> 4 CONTRACTOR ADDRESS O O uu E L i CA LIC S b 5?3 0 0 I CLASS <br /> R INSURER �� WORK.COMP.,-. (, R• _ <br /> A <br /> C FIRE DISTRICT �� LIT PERMIT <br /> T <br /> 0 LABORATORY NAME J� ^(S� CCi1NTY PHONE 3 <br /> 4 <br /> RSAL Skll TEC MrtIZS <br /> SAMPLING FIRM PHONE X <br /> TANK ID x TANK SIZE CHEM GALS STORED CllRRE4TLY/PREVIOUSLY I DATE UST INSTALLED <br /> 39- <br /> T 39- <br /> A 39- NK-15b-7y <br /> N 39- <br /> K 39- <br /> 39- <br /> _ 39- + <br /> P <br /> L APPROVED APPROVED WITH CONDI TIONS) _ DISAPPROVED <br /> A G- (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> N PIAN REVIEWER'S NAME ✓ DATE O�7 9 <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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF NIA." <br /> APPLICANT'S SIGNATURE: TITLE W"'t "��� DATE 1 J b <br /> CONDITIONS): <br /> (� �n�(_ ,4Z s.J4oG 4S�' TESfi4+r° GEwa4fD6.:gs ce,�tr�7y�75 <br /> EH 23 046 (Revised 7/10/96) Page 3 <br />