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ORIGINAL <br /> f7 �e �� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION 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 FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL __ TEMPORARY CLOSURE _ CLOSURE IN PLACE - <br /> EPA SITE "CAGLyy2PROJECT CONTACT a TELEPHONE # /Lr/,9RD /��lnl/GTO,v ZOrj 571;e 9653 <br /> F FACILITY NAMESiGL� Cte/,J� "it/G� o PHONE # �gZ ///� <br /> C ADDRESS Ic /1/h7if�A/s <br /> l <br /> L CROSS STREET <br /> i F OWNER/OPERATOR s' PHONE <br /> Y <br /> C I CONTRACTOR NAME PHONE # Zpg Vis! g6S3 <br /> O <br /> 4 CONTRACTOR ADDRESS �Z�� S�Yt7f/ �QQeSrC7� C CA LIC # 5oS/9B6S� CLASS y1,$1 46/1OXo <br /> T <br /> R INSURER S41PF.P/OR H&7-101✓H4 WoRK.coMP.# <br /> A w' y <br /> C FIRE DISTRICT l�'F-;Ve'L KA / PERMIT # <br /> r '-ABORATORY NAMEBeoAi✓ALyT//CAH.-L LA�c'J,CFJTO.e�Ff PHONE # 2o9 SQL 6x900 <br /> SAMPLING FIRM &0 N4G�/7/Lst'L & -00R q TO.eISS PHONE # Z09 J�� 0900 <br /> TANK <br /> IIIIIIIIIIII1111111111I11 <br /> TANK ID TANK SIZE CHEMICALS STORED CURRENT LY/PREVI WSLY GATE UST INSTALLED <br /> 39• <br /> T 39- / L7X� AcLovS D/C EL <br /> a 39• <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> L <br /> 9- <br /> 39•39-( A APPROVED A&ROVED WITH CONDITION(S) DISAPPROVED / <br /> A (SEE TACHMENT WkTM CONDITIONS) 2 g�9 <br /> N PLAN REVIEWERS NAME DATE o <br /> ' Iillillllllllllllill (IIII <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: "1 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 CCMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLCWINC: <br /> j "i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO VORK"c R'S <br /> COMPENSATICN LAWS OF CALIFORNI <br /> *IPPLICANT'S SIGNATURE: �q G/YnIj " TITLE Y/I�L �Jw✓' DATA- 9Y <br /> ..H 23 046 (Revised 7/10/92) Page 3 <br />