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r <br /> 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 /> 172 <br /> _X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE #C{)L-hCk-)/rx>o-i3 PROJECT CONTACT $ TELEPHONE # tit - 4-���1�1�.t= <br /> F FACILITY NAME I " <br /> - �CL�.CC�b{. •.) G�'�1[�l,t -< �fL - PHONE <br /> A <br /> J <br /> C ADDRESS 2 / Cry ! iZr i t i 1 1"' 1 "l o > <br /> I <br /> L CROSS STREET <br /> I 9 <br /> II <br /> T OWNER/OPERATOR PHONE # <br /> C CONTRACTOR NAME ' PHONE # /-I- � " <br /> 0 v.tJ5 1 > -v./ f - 2 3oV <br /> N CONTRACTOR ADDRESS r— 3 CA LIC # (� 3 ( CLASS A i7 R <br /> T L� <br /> R INSURER S, 1) WORK.COMP.# 1 Z L71 <br /> A <br /> C FIRE DISTRICT ^� �� C —, (';;C <br /> C1 PERMIT # <br /> T J <br /> 0 LABORATORY NAME (/L J'� "I��i � .I t lc PHONE # <br /> R <br /> SAMPLING FIRM PHONE # <br /> IIIIIIIIIIIIIIIIIIII..11rlllll <br /> TANK I # TANK SIZE C(;.i( CHEMICALS STORRED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39 // / ��� '(,'./ /O; 0r) / 67/i 1C <br /> T 39 /! / /0/ 4 I C //�I i i'� C k> 4)f <br /> A 39- 1- � /Cn <'CC� C L1 � iI/�'Gi•r' i + L � 11<'[irJ« Ll_ <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P IIIIIIIH-Mmillill ifilml 1111111111 if I I if I I I I I I I I I I I I I I ifTTTTT <br /> L APPROVED _ APPROVED WITH CONDITION(S) DISAPPROVED <br /> A - (SEE ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME ' �' DATE % <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Ittlifil I I I I fill fill I I I IIII III I WIFIRM I I I I 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 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 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIF N1A." 1 <br /> APPLICANT'S SIGNATURE: L '� TITLE /) C^ /ICS' DATE / I <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />