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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 ABANDONMENT IN PLACE <br /> EPA SITE # (2or©4C) S822C3h PROJECT CONTACT 8 TELEPHONE # yy�c7 J(3�Q t6tij <br /> F FACILITY NAME yl4 53,E p Krim PHONE # - D4Z� <br /> A <br /> C ADDRESS '2 cJ . iq Il3v rot le ��U Aevr'. �e\) IL CA <br /> , <br /> I R'_ i <br /> L CROSS STREETLC] t Z Q <br /> I - - <br /> T OWNER/OPERATORPHONE it <br /> C CONTRACTOR NAME Yy, �Q PHONE # (2o' 5-Z3 <br /> 0 - <br /> N CONTRACTOR ADDRESS CA LIC # C ��vL3 CLASS1��rp <br /> T <br /> R INSURER �-�� 5 � WORK.COMP.# <br /> A <br /> C FIRE DISTRICT � , {�,� PERMIT # <br /> T <br /> O LABORATORY NAME �' �.� yv f�� �}¢^ �(� �, PHONE # Sr't'Z L? oo <br /> R / <br /> SAMPLING FIRM PHONE # 'Z- 0u <br /> Ill 11[I!lI[Il I!![1tl II I1I111Ii <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- a 4.L/ L w C,ll OUNLl=.Axpr-03Jwnu <br /> T 39- 7 -ri1- C3 Q 00 Ln U kf" <br /> A 39- L U i Y►� <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> 111111111[1[Ill[11111[1111111[ 11111[Illlltlllll111111111I! III[I[1!1[IlII1111111Ililllllll11111Hi lI[IIIIIIIIIIIIIIIII[ <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> III 1111111111111!111!1111111111[11111Ii ll ill 1111111111111111111111111111111 111 ll 1111!til 11111111!111 it 111 11[Il 11 11 111 11 111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN "QUIN 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 /> "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." <br /> APPLICANT'S SIGNATURE: J[J\VJ.V � y.c�c_ _ TITLE a/CKG/ EST DATE F-7 I <br /> EH 23 046 (Rev 2/8/91) #t Page 3 <br />