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21 <br /> ` <br /> F. riVf' <br /> 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 /> v REMOVAL TEMPORARY CLOSURE 'ABANDONMENT IN PLACE <br /> EPA SITE #C4cooDS6D912. PROJECT CONTACT & TELEPHONE # mg If#4/(" /�}J> <br /> f F FACILITY NAME I PHONE # y� <br /> A 2DQ. .Y6,; s. <br /> C ADDRESS 2 41, riCJ�L /II ��q L-2-1Ct�TU[! <br /> I �V _ <br /> L CROSS STREETS� <br /> I , v <br /> T OWNER/OPERATOR PHONE # <br /> C CONTRACTOR NAME � � PHONE # ,aZ X653 <br /> 0 <br /> N CONTRACTOR ADDRESS !�3/ (/, i1r Q� CA LIC # �(�C/$� CLASS <br /> T <br /> R INSURER 1p4n/S�� WORK.COMP.# <br /> A ,1 81����� t/(/ <br /> C FIRE D15TRICT OF S� zD� "�RE �.P&vi5A1.rrd� PERMIT # <br /> 7 i <br /> 0 LABORATORY NAME /� L PHONE # 2091 SQ-Z- D 90l <br /> R �=l ,`�r1 <br /> SAMPLING FIRM 660 4W/-1/7-7 L PHONE <br /> liltll[I111[I1i111[iirrlll[rll <br /> TANK ID # TANK 51 E CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 1 3 D a- O �5�0 .tc-�o•✓ ,�l sSEC� C1.UKNocd.C/ <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 7APPROVED <br /> [111111i111111[II[111111111[I[I1lllrL APPROVED WITH CONDITIONS) _.DISAPPROVED <br /> A ( ATTACHMENT WITH CONDITIONS) p G� <br /> N PLAN REVIEWERS NAME DATE <br /> III II 11111111 Il lI I[I II I[1 1111111 it l l l 11 11 l l l l ii[I I Ir i1 r1[1111 l iI tl[1111[11[III 111111II I I i l i II I I III I l lII I l iII lI l l l lr 1111111111 <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 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 /> "F 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: TITLE ��`��G�� DATE 2 �l <br /> EH 23 046 (Rev 2/8/91) ftp Page 3 <br />