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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 /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # C �8 1 6ob3 PROJECT CONTACT & TELEPHONE # PftfMSIb9-33 .CS le, <br /> F FACILITY NAME S O PHONE <br /> A _ <br /> C ADDRESS 3 �(� C F <br /> I <br /> L CROSS STREET <br /> I <br /> Y OWNER/OPERATOR SH <br /> ccm <br /> PHONE #L(O <br /> C CONTRACTOR NAME O 1- etq PHONE # C,I0 v� -fq-a <br /> 0 <br /> N CONTRACTOR ADDRESS 5 SCJ �C CA LIC #,4,32 7, CLASS <br /> T <br /> R INSURER 57N— La v O E Fu KID S 5� WORK.COMP.#CJ-11-149 <br /> A <br /> C FIRE DISTRICTS v C PERMIT # <br /> 0 LABORATORY NAME 5�(XU��� N�LC� 41NdA NE�D2 PHONE # I� O'2 <br /> R <br /> SAMPLING FIRM ������ vE PoLS�t•J PHONE # f 6 -702 - Z I o <br /> IIIIIIIIIIIIIIIIIIIIII1111�111 Ok— SNC , <br /> T NK ID # TANK SIZE 47 CHEMICALS STORED CURRENTLY/PREVIOUS Y DATE UST INSTALLED <br /> 39- �- O flA 8 rlo SOLINL - UN�+UL� O <br /> T 39- <br /> ' <br /> A 39 o ' <br /> N 39 00 - jup <br /> K 39- <br /> 39- <br /> IIIIIIIIII II II I I I I I IIIIIIII <br /> P <br /> L APPROVED AP ROVED WITH CONDITIONS) DISAPPROVED <br /> A S E )FT CHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ul DATE L� <br /> IIIIII <br /> APPLICANTIIIIIIIIIIIIIIIMUST PERFORMIIII ALL WORK IN ACCORDA E 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 IFORNIA." <br /> APPLICANT'S SIGNATUR v TITLE \ ICs�� P��' DATE J <br /> C <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />