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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 /> _Z�REMOVAL _ TEMPORARY CLOSURE _ ABANDONMENT IN PLACE <br /> EPA SITE # L-4i•-��-6-V-098 PROJECT CONTACT & TELEPHONE #T �' 6an'K-V51-0733 <br /> F FACILITY NAME I PHONE # �JnC�•4rTa �p�'87 <br /> A Ol CO C•�� <br /> C ADDRESS I20(o t^ <br /> I [� <br /> L CROSS STREET <br /> 1 W <br /> T OWNER/OP�E,RA_TOR PHONE # <br /> Y MI � 209 4l g1 <br /> C CONTRACTOR NAME 1 n PHONE # <br /> 0 J.1 <br /> N CONTRACTOR ADDRESS (� 7 \ 2 P •�� Q- -� #(4s9C S <br /> � CA LIC <br /> 1' 4� <br /> T Jb V v C ID <br /> R INSURER 9--C <br /> C C e C/V WORK.COMP.# PC' OCCIL-155 <br /> A STo-wom ttrA pdp mem 1 1321" k 1328' <br /> C FIRE DISTRICT P IO V PERM/ CV <br /> T <br /> 0 LABORATORY NAME f40-1-14k-1 PHONE # <br /> R ff pp <br /> SAMPLING FIRM �_ �p(�` rockow PHONE 510-370 <br /> lllllllllllllillllllilllllllll <br /> TANK 10 # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- I 1�ri �}.S S 2 <br /> T 39 — 000 L t lif 7- <br /> A 39- _ �- DOO Lmuwep 111 Z <br /> N 39-� !J ! 17- 000 ti SEA ED �'l 2 <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIllllllllllllllllllllllllllllllllllllillllllllill111111111111111111111111111111111111111II11111111111111111111111111111 <br /> L ZOPPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A (SE TTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �k=6f llllilllllillllllllllll A-0IIIIIIIIIIIiIIIllillllllllllll1111llllllllillillllJllllllllllllll <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 /> "I 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." 11 <br /> APPLICANT'S SIGNATURE: TITLE%lack tVL"Ia2__ DATE 't•?A•Rl <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />