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1 ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> if <br /> 'i:ATION FOR PERMANENT/TEMPORARY CLOSURE OR <br /> ABANDONMENTIN <br /> PLACE OF <br /> 0� YESHADEDOAREAS >3ICATE''PFRMI51YOPEE3ELCII FACILITY <br /> 3 PERMIT EXPIRE5 94 DAYS FRCb! THE APPROVAL DATE. D i <br /> a <br /> REMOVAL TEMPORARY CLOSURE ABANDONMENT IN PLACE <br /> u <br /> ' �Y1 �/ PROJECT CONTACT � TELEPHONE <br /> 3I TE I Q(N K to <br /> ,f <br /> sLITY NAME 0110 <br /> a <br /> t <br /> SIS STREETPOI <br /> k <br /> PHONE 41 <br />'ER/OPERATOR <br /> PHONE M IJQ� 9 Z <br /> TRACTOR 4AME <br /> CA LIC $'7I CLs15S.Li <br /> , <br /> / /- ��yQ <br /> ITRAC T C'R ADORESS Q GF <br /> WORK.CCMP. C <br /> n <br /> PE.RMI T <br /> z <br /> RE DI5TRIC <br /> PHONE <br /> SCRATORY !TAME 1�2a <br /> ! PHON77E <br />�,VLING FIRM <br /> 111111111111111111111!111!! TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY OINS,,TALL-rll INSTALLED <br /> r-y wTANK iD # I i5r/ -./ �a ��S7 /- !11 <br /> 111111111111111llll1111l1!!1! 111!1111111 ;� <br /> APPROVED WITH CONDITION(S) DISAPPROVED <br /> /APPROVED <br /> —� <br /> (SEE ATTACHMENT WITH CONDITIONS) <br /> DATE <br /> PLAN REVIEWERS VAME <br /> i <br />�1111111111111111l11ll1111111 <br /> 11111111111111111111111l111111l111 11 11111111111111111111111111111111111l11111111111l111I111 <br /> ° 1I CERTIFY THAT IN <br /> LICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SANK LIC"—SED <br /> Try S GNATURES RIF ES ITHE F4L_OSIING{ND RULES AND REERTIF 0TH O $ <br /> I'I JOAQUIN COUNTY PUBLIC HEALTH SIGH THIS <br /> OWNER OR L <br /> PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, F SHALL NOT EMPLOY ANY PERSON IN SIKH A MANNER AS TO BECCM <br /> 3 <br /> G OR <br />},iECT TO WORKER'S COMPENSATION LAWS OF CxLIFORNIAi�� C��5C?ERMITHIS1Ii55UEDSUBCSHALLC��.i'IPLOYING IPERS NS SUBJEC7ETOTh'QRICER��I <br /> ICERTIFY THAT IN THE PERFORMANCv OF THE WQRK FOR dHICH <br />'4PENSATION LAWS OF CALIFORNIA." g i <br /> TITLE <br /> PLICANT'S SIGNATURE_ } <br /> Page 3 t <br /> 3 046 (Rev <br />