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ENVIRONMENTAL HEALTH DIVISION <br /> APPLIGTIOW 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 FRCM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X RF)C'JAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE XC A L 0 0 01 0 0 0 4 0� PROJECT CONTACT 8 TELEPHONE X J vdC C C C 9/6) 3 <br /> PHONE <br /> F FACILITY NAME <br /> A <br /> CACORESS a3 5 o wu cra Rd. <br /> t <br /> L CROSS STREET SIC r r a, i- G! 1'1 C. <br /> 1 <br /> T OWNER/CPEHATCR PHONE A <br /> Y UI+Yarn cc 121 = V'% /goy) 583 ^ 5593 <br /> C CCNTRACTCRNAME W[Mj40V\ E-ANZ rcc'rl »ci =hG. IPHCNEq� <br /> 0 <br /> Y CONTRACTOR AOCRESS nn G LIC '� / 7 w CLASS <br /> a5 .,j. Sac. c� Rs6 t 3 <br /> T <br /> � R INSURERn• n ;Z WCRK.CCMP.4 <br /> uU� Oa1 m2 [1a OROS° <br /> A 2cmoUG — 140T3 <br /> j C FIRE DISTRICT I �' PERMIT X <br /> T / <br /> 0 LABORATORY NAME IIJG Rn/a, J T11 u / PHONE d <br /> R <br /> SAMPLING FIRM ppC+,Dtl Y)I•C /< C /66/) Von DG VYL PHONE 9(99/11 93 c1^ �SSo <br /> IIIIIIIIIIIIIII llllllllll�III / <br /> _ TANK I / TANK SIZE CHEMICALS STORED NRRENT Y/PREVIOUSLY DATE UST INSTALLED <br /> 39- O G»5 0/i Ile L- <br /> I/ <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P <br /> L APPROVED APPROVED WITH GOND IT IONS) DISAPPROVED <br /> A - _ �. (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME - v1 �-�` � DATE <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN 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: ul CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL MOT 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 /> 9 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: / ��/ 1 - TITLE � , DATE OGT 3 <br /> TQ s f ca <br /> E4 23 046 (Revised 7/10/92) ._._ Page 3 <br /> J - <br /> .—.x <br />