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Copy I <br />54/� RECEIVED <br />ENVIRONMENTAL HEALTH DIVISION O V 2 2 1994 <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <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 />t/ REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />1� 4 <br />EH 23 046 (Revised 7/10/92) Page 3 ENVIRONMENTAL I!E,,\LIN <br />PERMIT/SERVICES <br />a <br />4 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE #Iqi �. �Lfe�f'i <br />F <br />FACILITY NAME <br />A <br />C <br />ADDRESS <br />CA <br />I <br />L <br />CROSS STREET <br />T <br />OWNER/OPERATOR PHONE # <br />Y <br />ill+'Dlx� 2 <br />C <br />CONTRACTOR NAME <�,r�.� qPHONE <br />3 <br />N <br />CONTRACTOR ADDRESS CA LIC # '�� <br />b 1.sr .5�_�1�, <br />CLASS C I <br />T <br />R <br />INSURER <br />WORK. COMP.# 6016 <br />A <br />C <br />rFIRE DISTRICTJ ® <br />PERMIT # <br />T <br />LABORATORY NAME �! <br />PHONE #-,5-/o -.- 8 ,7 <br />SAMPLING FIRMA <br />!� /� �• l�< PHONE #ZC jj <br />II IN��i L <br />TANK ID # TANK SIZE CHEMICALS STORED CURRE LY/PRE IOUSLY DATE UST INF7ALLED <br />i ) Iii -' <br />A <br />39- O - <br />00 <br />EiE <br />`� <br />K <br />39-45 <br />M4, <br />39- <br />39-��� <br />_ <br />I'II�II'lll'II I ' I I ' ���' �II II' I���" �' ' Illlllllllllii <br />P <br />L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br />A (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATION. OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY T`AT 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 BECC"_ <br />SUBJECT TO WORKER'S COMPENSATION LAWS F CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE F SLOWING: <br />"I CERTIFY THAT 1N THE PER E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORK -R'S <br />COMPENSATION LAWS OF CALIF " '� <br />APPLICANT'S SIGNATURE: __ TITLE R�'S DATE <br />1� 4 <br />EH 23 046 (Revised 7/10/92) Page 3 ENVIRONMENTAL I!E,,\LIN <br />PERMIT/SERVICES <br />a <br />4 <br />