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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 # C OOO"f 324-B <br /> PROJECT � rCOONT-ACT & TELEPHONE # CtVI( <br /> F FACILITY NAME '(lZft(��( MUNiCAPkL NJKPC)FZI PHONE # 2O1 sss;-426G <br /> A p �f Tb �/ <br /> C ADDRESS ZC�,�j33 S . -MAC` BLS <br /> I <br /> L CROSS STREET r <br /> OWNER/OPERATORU"[`( CF Tp n Gv PHONE # ^ r _'I" 0 <br /> C CONTRACTOR NAME kyjr , eyjv\r>n yer Q SeT-V-CfeS PHONE <br /> 0 <br /> N CONTRACTOR ADDRESS <br /> -,VIM CA LIC # 66q-6B5 CLASS R $ (.-fes <br /> T f�,, r <br /> R INSURER '� A �h Com_ WORK.COMP.# WC680 U6�I00I <br /> A <br /> C FIRE DISTRICT ' F-W '{=lf2E—DEfj' WILL Pie ON 43IIE Fop PERMIT # NOT A-dAILP� <br /> T <br /> 0 LABORATORY NAME Wj �� jjC � ��� PHONE # SIC) — 619—8989 <br /> R SAMPLING FIRM - WICi• G{�VIYU1 �l(eS PHONE # 310— —1`11- 3-7 <br /> liiiiiiiii11iiiiii illi1illill <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- <br /> 3 39- in0n nn b\�S'�EL Iq zw-)I S 7 � <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> ���1 11����11111��11� �11�111� 11����� � � 11�1��1111 111 � ��111111��1111��������������111II 11II11I11I�1I111�� <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A ` � ppp (� ( E(�T�`flHMENT WITH CONDITIONS) n�- <br /> N PLAN REVIEWERS NAME 4 ~ x=u - i;\I�1-c X.t 1[ pnp DATE ' %v <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."1 ^ — <br /> APPLICANT'S SIGNATURE: TITLE STATE 1=P f INE2 DATE g�11�gS <br /> yf Dw� EyCca�o� on1 A �rNki is c� seoJEtr�d /off do+�a�cd Fs�s r\\ws-l- bF P)a:C( <br /> G�ct -h-aalc- Q�Mo�-cd. <br /> Ail aoilg An1cLl�s;S �� Mak aN� Ossac c+�t� p P;a� If.� st � �ollo�J � W,4)N <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />