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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 HAZARDCUS 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 /> ,l—x REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE ;* C4C0007PROJECT CONTACT a TELEPHONE $ OW W&M(LZ' PJ Lz.oq SZ�,�6,s3 <br /> F FACILITY NAME t�$�.N PHONE 9 ?,Oe() �l'q X013 <br /> A /, d <br /> C ADDRESS lU� ufEF LcNeOLN n 1 <br /> I <br /> L CROSS STREET <br /> I v,iT1�LG <br /> i OWN AERATOR PHONE T i <br /> Y SAaI �R�l�lCGS2O iEEiUC l?j�Ej (5-10,1 5-6 fS—SS 11 I <br /> C I CONiRACTOR NAME sCi LD PHONE R <br /> 0 ZO 9 SZ 5l 9653 <br /> rCONTRACTOR ADDaEss TN 0,4Oe57-0, CA Ltc S.�Sl9a6� I cLASs,q�f�, <br /> 2 tusuaER �%VPf�2j 0� ,4,t /Nsl '+ Rx.CCA!P.- 3 (,2� y , <br /> c FIRE DISTRICT C/7—Y OF STOCKToh/ PERMIT 9 i <br /> r <br /> O LABORATORY NAME 6'eol��I.a��Tif4L <br /> 2 LA�e97o,e/�f I PHONE x Zaq SQL 6900 <br /> SAMPLING FIRM &O /v?��'/?/L.qL (�A 012 V41rs PHONE 2Qg nZ D90� <br /> llllllllllllllllllllllilllll!! <br /> TAN? IDD/ �OOTA (D A---CHEMICALS STORED CURRENT LY/PREVICLSLY DATy IJ$ INSTALLED <br /> 3 <br /> 9 -O (gg Cj/� D LI AJC _//�( <br /> r 34- L � <br /> tr0 n A S a L[ �- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P II1111111111111111111111111111 !111111 III111111! I1! 111 Ili! 11l1i111lI111111 !I1 Illllllllillll1111 11111111 111111111111 <br /> L APPROVK APPROVED WITH CONOITION(S) _ DISAPPROVED <br /> A (SEE ATTAC. NT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE <br /> 11111111111!11111111 III11 ! <br /> APPLICANT MUST PERFCRM ALL WORK IN ACCORDANCE WITH SAN J CUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOACUIN 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, 70 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 CALI OR IA." <br /> APPLICANT'S SIGNATURE: ��Y1V YY� TITLE I�/W� DATE <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />