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i • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSU5E 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 /> REWNAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> fPA SITE # ����l�j �L�g l PROJECT CONTACT & TELEPHONE 'rc �I°1 fJ`�,7 `-GSA <br /> PHONE # ��. g Z2, '-J-�•�S <br /> F FACILITY NAME j <br /> C ADDRESS 10 , AlAlex) J Trz -2�T` <br /> I <br /> L CROSS STREET 5� <br /> I PHONE <br /> T OWNER/OPERATOR <br /> Y <br /> C CONTRACTOR NAME ' IV V PHONE uq-7--Z, p� <br /> 0CLASS <br /> N CONTRACTOR ADDRESS LIC 7C7 z-,-z-I <br /> WORK.COMP. <br /> R INSURER Jll4L fLwD� <br /> A PERMIT # <br /> c FIRE DISTRICT CF 01 ['I< Tni <br /> 0 LABORATORY NAME ; I(� C � �PHONE �#(ce;f y �'RSAMPLING F1RH �V �RcJPLSL� � � <br /> IIIIIIIIIITANK ID# "'��I' TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> TANK IO # � a.�'7by�rr�.,.' �se�.z��.�� J "v✓r�.s` <br /> T 39- 7 .% <br /> A 39- <br /> N39-7m- — <br /> K <br /> 9- - <br /> N 39- <br /> K 39- <br /> 39- IIIIIII ���� <br /> [IIlli I II <br /> PAppRpyEp APPROVED WITH CONDITION(S) DISAPPROVED <br /> L � _� <br /> L ATTACHMENT WITH CONDITIONS) DATEN PLAN REVIEWERS NAMEIIIIIIIIIIIIIIIIIIII 4����� <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, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> "IBCERTIFYY WORKER'S <br /> INSTHE PERFORMANCE OF THE WORK FORAWHICHOTHISCPERMITHIRING <br /> ISSUED,UICSHALLLLCEMPLOYSIGNATURE <br /> PERSONS SUBJECTETOTHE <br /> WORKER'SWING <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: - TITLEJ,-1t7� <br /> DATE �� ��07 <br /> QS <br /> AWL?1n C 2;A*, . ck To'LbL0 LrZAd P-d 1::"u9-1 LC2, ea;A <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />