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wl <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <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 # A PROJECT CONTACT 6 TELEPHONE #"1 rJ 2/ , -Z'17-1109 y /1 <br /> F FACILITY NAMEp / 7 D _ _ _ D 0� PHONE IL,_y cl y <br /> C ADDRESS .� .GfJ <br /> I I 7 4 1 t1RG S Li <br /> L CROSS STREET <br /> T OWNER/OPERATOR PHONE # <br /> Y A I G 1 - 3,288 <br /> C CONTRACTOR NAMEpE Ai T PHONE #�1 3 _ p `/ c7/ <br /> 0 / / <br /> N CONTRACTOR ADDRESS LOSS MORLE9 CA. 9,1609CA LIC # � CLASS <br /> T Q DM 007 OAL S T N <br /> R INSURER — WORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 0 LABORATORY NAME V���ti�� 'V _ `>����) � ��( � ,f PHONE # <br /> R SAMPLING FIRM ( • !- 'ej- PHONE # ' <br /> Iilillllllllllllllliplttltltl y �/H 5`60-K5-52- <br /> TANK <br /> STANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39-CA0000597392 &LI 6 ;11 . DI ES -L l- 3 G `f <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 71PPROVED <br /> L APPROVED WITH CONDITION(S) DISAPPROVED <br /> A / (SEE <br /> //�TTA/Q, ENT WITH CONDITIONS) <br /> PLAN REVIEWERS NAME -�i ��ti� (0-C I l.' DATE • //� C/ <br /> N IIIIIIIIilllllllllllllllll�fl# IIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 111111 IIII11111111 <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: 1-1 CERTIFY THAT IN <br /> THE PERFORMANCE OF'THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 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 WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.""/' y�J Q <br /> APPLICANT'S SIGNATURE: H✓LVA ri( �� Q.r� TITLE /Jcciu2vvi 4 DATE 05"-& <br /> �� <br /> EH 23 046 (Rev 2/8/91) FL Page 3 <br />