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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 FROI4 THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> ' REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT Z TELEPHONE # 9111 <br /> �r `1' 1- <br /> F FACILITY NAME J JbA p rJ � ? /ynVlzL PHONE # ]�J_ <br /> A <br /> C ADDRESS <br /> I --!5r7ou, � <br /> ' <br /> L CROSS STREET ��A52 Yil� ep <br /> (] <br /> I <br /> T OWNER/OPERATOR rrte+ PHONE # <br /> Y f Qo f l A-,-eb, la <br /> C CONTRACTOR NAME w PHONE # 0q. <br /> 0 <br /> N CONTRACTOR ADDRESS ' CA LIC # '2 CLASS <br /> TCJ C. G rr3r�1 rC•6i..�yl�� y*' <br /> ' R INSURER lis l �' r; WORk.COMP.#-(� c F,�r4 Ey,, �/ <br /> A ! J U �' <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> ' 0 LABORATORY NAME PHONE # 67f _ 0 <br /> SAMPLING FIRM PHONE # <br /> rirrrrrrrrrrrrrrrrrrrrrrrrrrur <br /> TAK ID # TANK SIZE CNEMIS STORED CU RENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- l 0 t Lod 0 15 U1lrlA10 11 <br /> T 39- /17/J11) <br /> A 39 <br /> K 39- <br /> 39- <br /> 39- <br /> rlrr <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A I: ), (SEE ATTAfRNEHT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> rrrrrrirrrrrrrrnrrr mil <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 CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �_ i'^' s `i" l = ' '�'� TITLE / • DATE <br /> LQ �,- ��fi s ; i►�:ll 1 bs fry P <br /> h i f it/000 %4 <br /> cr .. <br /> . c_ <br /> 1e„ <br /> EH 23 046 (Revised 7/10/9 f � P?e �l <br /> S - Gnyv�'•'-t�' r►tz-4��' �L;,�.{.,`� a'"`'- 1 . � C,. dV� Y►.+��Lb�-'1� <br /> sdQ.. <br />