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i <br /> l <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH.SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN 'ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> XREMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # PROJECT CONTACT 8 TELEPHONE # U&WT <br /> 47 f5� <br /> F FACILITY NAME PHONE # <br /> A <br /> C ADDRESS 3 r` c-;T r,CE-T <br /> I <br /> L CROSS STREET A 5T. W iEES C11 ;_ <br /> I ! <br /> T OWNER/OPERATOR � ,,J PHONE # 4 L <br /> C CCNTRTOR-NAME bS- ! ' ' PHONE # <br /> � ACjJEt.. 1 �l. � 111.. .1 <br /> N CCNTRACTOR;ADDRESS i b 66 6 14 5- ME) FcA LIC ;O CLASS <br /> R INSURER WORK.COMP.# <br /> A <br /> C FIRE DISTR4CT rw— 04PERMIT # <br /> r L- <br /> O LABORATORY NAME S 5' COUNTY ��,� I PHONE # C 6� <br /> R <br /> SAMPLING FIRM (�. `i`L.rLi " �Yy 27 PHONE # ,(t <br /> � IIIIi11111111I11111T1i11i111[I - <br /> TANK [D # TANK SIZE CHEMICALS STORED CURRENTLY_ (?REVIOUS DATE UST ]NST LLED <br /> 39- L. 9S'�G' I.� T6 <br /> T 39- L� <br /> A 39- - <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> � P lIIIIlllll![Illli IIII11[I111 ! 1 1 IllII111111I I[III.I[IIIII II1111111i111111[lilllllllllllll[lllll! 11111111IIlIlllilllll <br /> L APPROVED APPROVED WITH CONDITION(5) DISAPPROVED <br /> A ( EE ONDITIONS SELOW,AND/OR ON ATTACHMENT) <br /> N ^ - l i <br /> PLAN REVIEWER'S NAME DATE /0 -7 <br /> � 1 <br /> IlIIIIII IIII'll IIIIHIM IIII 1111[IIIIIIIlll111III III 11 1111111111111 E.11111111111111111[IIIIIIII[Illillllll111l1lIIII1IIlIIl1 <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 /> "1 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." <br /> APPLICANT'S SIGNATURE: 1 L TITLE ��� DATE <br /> CONDITION(S); <br /> Lo <br /> Lt�J <br /> cL m <br /> EH Zvis a9e 3 <br /> --W-- <br /> 7.1r �lCv✓�G'1� %`" �`' - ":c1 L�,-u/4 �j' `� '��L�.S� u � 4 <br />