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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. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />c/ <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />1A11141111 <br />EH 23 046 (Revised 7/10/92) <br />Page 3 J N N 0 3 1993 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY NAME T- <br />14 Lp-� 2 <br />PHONE <br />1e 8 <br />Chu <br />A <br />C <br />ADDRESS 13 <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />CONTRACTOR N G. <br />PHONE # � J <br />N <br />CONTRACTOR ADDRESSp L� <br />CA LIC # <br />CLASS <br />T <br />R <br />INSURE!:22 <br />WORK.COMP.# b <br />�G <br />A <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME <br />PHONE # <br />R <br />SAMPLING FIRM <br />PHONE # <br />iANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANK <br />39 S - o /d 000 �Ces _ <br />r <br />` I_ <br />T <br />39- - a 2 /O� x),00 U L <br />— <br />A <br />39 S _3 /)20 ^ <br />N <br />39- <br />K <br />39- <br />39- <br />39- r <br />P <br />L <br />APPROVED APPROVED WITH CONDITIONS) <br />DISAPPROVED <br />A <br />( ATT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />IIII III llllllllllllf ITINFITMIIIIIIIIII <br />DATE <br />T1TmlIII I <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 <br />CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY <br />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, <br />1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />- <br />APPLICANT'S SIGNATURE: ' TITLE <br />DATE L/ <br />1A11141111 <br />EH 23 046 (Revised 7/10/92) <br />Page 3 J N N 0 3 1993 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />