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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR pEpMANAPPLICATION FOR UN)ERGROIAND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIENT/TEMpORARy CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARD <br /> T EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO HOT WRITE IN ANY SHADED AREAS. W <br /> S SUBSTANCE STORAGE TANK INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE ,. <br /> EPA SITE / gyp• A ^ ¢, CLOSURE 1N PLACE <br /> ( / v "OZZpj E 9 <br /> A PROJECT CONTA ELEPHON <br /> F FACILITY NAME M� F 'S'i` 'AN 1 1 - a - 1084- 4380 <br /> 1 ADDRESS 2 q s PHONE / <br /> I 1 STac.KToIJ �`�`� • 3� <br /> L CROSS STREET 1 ISI 5 <br /> I <br /> T OWNER/OPERATOR <br /> Y -Z SElz <br /> PHONE A <br /> C CONTRACTOR NAME <br /> }*.2 t 3- (1aa- 4- 0 <br /> u v- <br /> 1 LF S�. <br /> CONTRACTOR ADDRESS Z PHONE S <br /> R INSURER G LIC S �' CLASS <br /> C FIRE DISTRICT A-I(L O+J WORK,COMP.* <br /> T <br /> RO LABORATORY NAME Com- PERMIT S <br /> SAMPLING FIRM PHONE S <br /> TAN <br /> IIIIIIIIIIIIIIIIIIIIIIIIIII — <br /> rANK ID of vxoxE <br /> 39- -L_ TANK SIZE <br /> T 39. � L 1�-Z _ o O CHEMICALS STORED CURRENTLY/PREVIOUSLY <br /> A 39• " DATE UST INSTALLED <br /> Z_ a 17NLh <br /> N 39- o00 (Aj <br /> K 39• <br /> 39• -_ <br /> 39- <br /> P <br /> L <br /> A APPROVED WITH CONDITION( <br /> M PLAN REVIEWERS NAME ATTACHMENT VITN CONDITIONS) — DISAPPROVED <br /> I I I I11111111111111111� <br /> DATE 11111 -S� <br /> SAN JOAWiM COUNTY PUBLIC <br /> APPLICANT NUPERFORM ALL WORK IM AC ITH SAN JOAQUIN COUNTY ORD[MANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> NEALTM CORDANCE WSERVICES. OWNER OR LICENSED AGENT'S S <br /> SUBJECTToWORKER'S <br /> OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, IGNATURE CERTIFIES THE FOLLOWING: " <br /> WORKES S COMPENSATION LAWS OF CALIFORNIA." I SCALL NOT EMPLOY ANY PERSON IN I CERTIFY THAT IN OBECOME <br /> THAT IN THE PERFORMANCE OF THE TRACTOR'S MIRIN <br /> "1 CERTIFY TG OR SUBCONTRACTING SIGNATURE CERTIFIES THEFOLLOWING: <br /> COMPENSATION LAWS Of GLIfORNIA ■ WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> APPLICANT'S SIGNATURE; I I' I I ,, <br /> TITLE �C/v Nj w'/?D <br /> DATE l <br /> r.-zf <br /> EH 23 046 (Revised 7/10/92) p S Co vl'P 'yI ✓e�� ne Y. <br /> �I/ S Sa eo�3 r 14 L <br /> ✓ Sa,�wli `1 rc/, <br /> 3o tis J) jcyrcL ro I000 �- <br />