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ENVIRONMENTAL HEALTH DIVISION w��}YYY ` /���ttt F1� <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT RECEIVED fE C p4E I \l E t 1 <br /> �THISAPERMITFOR <br /> EXPIRESN90TDAYS OM THE APPROVVALRY CLOSURE OR DATE ABANDONMENT DOIN PLACE NOT WRITE OIN ANYERGROUND SHADED AREAS.HAZARDOUS <br /> ANCE <br /> ERM rIB�OWp� �!/] <br /> E.NV�RONMEENTAL HEALTH <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE PERMIT/SERVICES <br /> EPA SITE # C�C' v�V b�9� Z PROJECT CONTACT 8 TELEPHONE # 04oE <br /> F FACILITY NAME �IL / A n PHONE # <br /> A <br /> C ADDRESS3/ • IO (W/ Op r- FA/ <br /> [ rC, f <br /> L CROSS STREET Ct DO FZ T D <br /> t V •\IJ <br /> Y L OWNER/OPERATOR D ��� PHONE # <br /> C CONTRACTOR NAME St�m LO PHONE #/fn9, c�'Z Q6S3 <br /> 0 ; <br /> N CONTRACTOR ADDRESSOQT0 CA LIC # CLASS <br /> R INSURER 71?4NS )qm 0,zt WORK.COMP.# O//ham, iT"/ <br /> Y'" C, <br /> A pp <br /> C FIRE DISTRICT NL� rvtP Z4/' �Z PERMIT # <br /> T <br /> 0 LABORATORY NAME (CAL PHONE # 201, <br /> S�Z r o�IOO <br /> R ,I <br /> SAMPLING FIRM Geo 776-IZ- PHONE #2Qq, S?2• jDa <br /> III II III II III II II III II III II III <br /> 39- ZTANKTANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST ,INSTALLED <br /> 7� <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIiillllllllllllllllllllllllllilllllllllillllllillllillllilllillllllllllllllllllllllllllillllllilllllllllllilllllilllll <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ,JSEE ATTAC�HMEyZ WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �\ �"—' DATE <br /> III II Iil l l 11 l 11 11 11 l 11 l l l l l 111 11 111 11 11 111 11 111 it lil 11 11 11 l I III if III II III II II 11111-111 II III II II III II III if III II III II II III II III <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: '11 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE (ARK 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 /> "1 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 CALIFORN)IIA.�° �'' /,�/ / ,/ <br /> APPLICANT'S SIGNATURE: 2"`�'�l <1 M./�NY! TITLE DATE / <br /> EH 23 046 (Rev 2/8/97) ft Page 3 <br />