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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�L ©�I�, Z PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME 13e� 4= !� PHONE 2 ` �, <br /> A <br /> C ADDRESS,,?3 C) L✓�- % �''`�. {�, S:or rC -,/ , <br /> L CROSS STREET <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> C CONTRACTOR NAME PHONE # <br /> 0 <br /> N CONTRACTOR ADDRESS CA LIC # CLASS <br /> T <br /> R INSURER NORK.COMP.# <br /> A <br /> C FIRE DISTRICT PERMIT # <br /> 0 LABORATORY NAMEPHONE # <br /> R <br /> SAMPLING FIRM <br /> M-Ll f vi:�:- _ PHONE #clA, - 7 ss <br /> IIIIIIIIIIlIIIIIIIIIIIIIIIIIiI � - <br /> T NK ID # TANK SIZE CHEMICA la` STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- - f /':� ty:at� ✓� %/.,�1L�n/� v1/ <br /> T 39- / - <br /> A 39- - <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> llll � <br /> P <br /> L APPROVED _ APPROVEIYCONDITION <br /> (S)CONDITIOS} _ DISAPPROVED <br /> A (SEE ATT AC/W(ENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> Illlllllllllllllllll 11111 <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 PERM] IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIF NIA.° CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WOR FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> J <br /> APPLICANT'S SIGNATURE: TITLE �� IIL� DATE <br /> V� <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />