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r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE FACILITY <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 E #IAC Ob062(o�l(p , ROJECT CONTACT 8 TELEPHONE # <br /> F FACILITY NAME / ' Q PHONE # <br /> G <br /> A T <br /> 70 / <br /> C ADDRESS <br /> I <br /> L CROSS STREET < CK <br /> I V iC <br /> T OWNER/OPERATOR PHONE # <br /> Y G�ynr1 6A Ike- 1209l• / <br /> C CONTRACTOR NAMEPHONE # no�j_ '9 q <br /> O /"r1 ��C✓ e✓v i /T 10 i-7 <br /> N CONTRACTOR ADDRESSZ7 jC CA LIC #y/ O� CLASS �, /D - y0 <br /> T <br /> R INSURER k r N WORK.COMP.# 2 <br /> A <br /> C FIRE DISTRICT -Sc PERMIT # <br /> 1 'mk r�._ r <br /> 0 LABORATORY NAME AVIO f� PHONE # <br /> R f- <br /> SAMPLING FIRM �i ! i S, i5n✓rte/�,i/A Tc.L PHONE # � z/— /D / <br /> illllllillllllllllilllllllllll L 7 <br /> TANK- 10 # TANK SIZE CALS STORE CURRENTLY/PREVIOUSLY DATE UST 111 TALLED <br /> 39 D 0O4 �e Q s l- <br /> T 39- 'OZ- DP o U cQ S <br /> A 39- - L <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P III II III II III II II III II Iil it III I I II111111111111111111111111 II 111 11 111 11 11 111 11 111 11 lil 11 11 111 11 111 111111111111111111111 <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A TACHMENT WITH CONDITIONS) / <br /> N PLAN REVIEWERS NAME l/ " ' DATE <br /> IIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII IIII IIIIIIIIIIIIIIIIII <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." <br /> APPLICANT'S SIGNATURE: Oeei Ivies TITLE 4/ DATE 2' / <br /> EH 23 046 (Rev 2/8/91) ft Page 3 <br />