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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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> i <br /> EPA SITE #r_ . 1 �., � )! ! )C. V i PROJECT CONTACT & TELEPHONE #A <br /> F FACILITY NAME'; - - �_- PHONE # <br /> C ADDRESS !- --- — �I <br /> L CROSS STREET <br /> I <br /> T OWN R/OPERATOR • _ PHONE # <br /> C CONTRACTOR NAME ';� I -r PHONE <br /> N CONTRACTOR ADDRESS,.! �I. CA LIC # - !` CLASP i <br /> i � <br /> R INSURER f' r ) i� - � �/ ; �,r 1p"J)/_�, WORK.COMP.# <br /> C FIRE DISTRICT • - I ;, ,i /' PERMIT #- -- <br /> 0 LABORATORY NAME / PHOyjE;# <br /> R - <br /> SAMPLING <br /> F�I�R�M ' PHONE #5;xi11111�� //, <br /> SANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- -U <br /> T 39- / O <br /> A 39- /4 Z/ O <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> ����������������������������I� <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A ( EE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME 7� DATE <br /> ��� 11"111[11111111111 iffffrffmTmTllllllffffffffffmTrffffffmTfffff <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 SERV"" <br /> OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORT( 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 P RFORM E OF HE WORK FOR WH ICH. TH IS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CAL ORNI <br /> APPLICANT'S SIGNATURE: - .L TITLE DATE <br /> ��/� I <br /> 1C)n 5 <br /> `7- <br /> �h� C.c..c.i-o1w- <br /> 3e) 60-Lf,% <br /> E. `. sv�/2 i Page 3 <br />