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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 />iC REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br />n g <br />•� -aha•-�'�-y >t}nalysls �'�- crr�/eade��a.�. <br />USA d (� <br />EH 23 0046 (Revised 7/10/92_)I Page 3 <br />�✓\�,l.A �'C- `�� Y✓1 � � _QyU�.- ��� �V� b-C'X_'' l5 <br />EPA SITE #��r'�70G'Z�t7 <br />PROJECT CONTACT & TELEPHONE #kwel <br />F <br />FACILITY NAME '�IGSr�liODJ <br />PHONE # <br />A <br />C <br />ADDRESS (,�•pC2l p <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />C <br />CONTRACTOR NAME�µG I '� 6 <br />PNONE # gllP ?J.g` , 00 <br />0 <br />N <br />CONTRACTOR ADDRESS <br />CA LIC # <br />I CLASSA <br />TWORK. <br />R <br />COMP.#'T �2 <br />INSURER Z 1 -' <br />C <br />FIRE DISTRICT W PERMIT # <br />TPHONE <br />0 <br /># <br />LABORATORY NAME �✓�.D•�j'72• CD� <br />R <br />SAMPLING FIRM X11-Gt3K�L°pC60N,4L. TE5C- mvuq&Y PHONE # 51r, S L IIC�0 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- A000 C� 7LINTr _ Ili-tl�-obi--i /.�A. t.INtE f INKJ�(G..IN <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />iiii r � <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />_ <br />A SEE ATTACHMENT WITH CONDITIONS) 2 y ` <br />T J <br />N PLAN REVIEWERS NAME 'L� "�`- �(L'-1Lc\ -- DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE ITH 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: 'II 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 />"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA.• <br />II�V. ,1, I,./,., �� <br />�� �'�' L35 zY�C�ttZ` 91TLE T ;=IU (Y C,a.i�C(.-c�AI� DATE IS <br />APPLICANT'S SIGNATURE: <br />n g <br />•� -aha•-�'�-y >t}nalysls �'�- crr�/eade��a.�. <br />USA d (� <br />EH 23 0046 (Revised 7/10/92_)I Page 3 <br />�✓\�,l.A �'C- `�� Y✓1 � � _QyU�.- ��� �V� b-C'X_'' l5 <br />