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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 /> REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE #C A L 000I00 O �} owl PROJECT CONTACT 8 TELEPHONE # TUOC Z (: e- <br /> F FACILITY NAMEC!(GDN �.f- ` y/ PIICNE # ao9 y6� _ ys6'9 <br /> A <br /> CN"s a 3 s 0 W cTTCY• UI <br /> OSS STREET 61 Y) C. <br /> I <br /> T OWNER/OPERATORPHONE # <br /> Y UI }ca vvuY� 1 = vac elo9) 583 - 5598 <br /> C CONTRACTCR NAME W4�+Oh �VTa � I"CC'I'Ih S11C . PHONE <br /> 0 <br /> N CONTRACTCR ADDRESS L,> aS W. SQG. Cll Rs/i CA LIC II 3 S CLASS B Gzz' <br /> T <br /> R INSURER U p- 1tCRK.COMP.# U C3 Oo7 ( a 9 oZ 06 c6q: <br /> AfLcmovG — I �f O$3 <br /> C FIRE DISTRICT PERMIT # =nS-I•n a! — 1 L- O ' <br /> T <br /> 0 LABORATORY NAME W L IJQ, T A/ i� 4 V 1 5 PHONE # <br /> R SAMPLING FIRM C+D/1 /)')I•Gl< C /5U/') Vanquw( <br /> J� 11 PHONE # <br /> TANK I11��������1��� <br /> TANK_Ij) # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- / 764 064 Gnsn li if (//�+ <br /> T 39- - �� �/ — G�/L <br /> A 39- - <br /> Orem C <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- l �1 <br /> Illiffmi4ff <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A _ (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME - '��7 � '`�- DATE <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 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 (ARK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: �.��� � - TITLE �Oilm i //�Y DATE OCT 3 <br /> EH 23 046 (Revised 7/10/92) Page 3 ._ <br /> a <br /> 3 <br />