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i <br /> i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> ANCE <br /> APPLICATION <br /> FOR <br /> PIRESN90TOAESPFROMYTXE <br /> CLOSURE <br /> 4ROVAl pgTE.NM00TNOT WRITEIN INOIN AmySHADEDAREAS. INDICATE TPE MITTTYPE EBELNOW: <br /> PEPJ4 <br /> REMOVAL _ TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE tl CACLA'(ZOS'ILl32 <br /> PROJECT CONTACT 8 TELEPHONE X L.�, 7-)CJ)lr•�d^ C� Ib� �3C� -ZH�-i L-) <br /> PRONE 3 C2toq '13 —'733-1 <br /> FACILITY NAME NOL' C�.1- S S '3� $ to <br /> ADDRESS 2'101 I^I' Y'Ii1drL)•-� Lr . <br /> S-Eo�1t--lw. C> GS'Z19 <br /> CROSS STREET 1f��ClS�-�+k� 5 I PHONE 1 <br /> OWNER/OPERATOR CSIS� lS5H --1022 <br /> Union <br /> 11 I PRONE 9 CQI b7R 2&- '63oU <br /> 7 � rJ <br /> CA LIC Y (n C1 5 'i 8 -1 I CLASS <br /> 4 CONTRACTOR ADDRESS N 1!.7 <br /> - I YORK-CG1P.ilCZ-INNBb - b0 i <br /> INSURER <br /> � r I PERMIT x � <br /> C FIRE DISTRICT G)+ oY S-1'o.��')'�/� PHONE A' (510_) 1e Lo 00 <br /> 0 LABORATORY NAME v�t7>a 11 b li 3g 2 <br /> R SAMPLING f1RM +a' Lin✓ �d PRONE + (! OGLE <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIiI TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY I DATE i�K'STALLED <br /> TANK ID S 70,000 (a3l�o'^,S dim'--S 1 14 SZ <br /> 39- U 1 Z 000 �� K'1 oC tdr�G > -!-✓� 1 9 K Z_ <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- I <br /> 39- <br /> 39- �1 1 1 1 i 111 TI1111 1 I111 illl iilllllll IIIA <br /> 11111 DISAPPROVED <br /> P APPROVED APPROVED WITH CONDITION(S) J�, <br /> L SEE ATTACHMENT WITH CONDITIONS) DATE 0— <br /> L <br /> A <br /> H ?LAN REVIEWERS NAME I11I1 <br /> Illillllillllilllill <br /> APPL[CANT MUST PERFORM ALL WORK IN ACCORDANT WITH SAN .1DAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN IOAOUIN COUNTY PUBLIC HEALTH SERVICES- OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "! CERTISECOM FY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUI , ORpSLXIR INHOT GOROSUBCONTRACTINGY ANY PERSON N SIGNATURE ACERTIFIESOTHE FOLLOW <br /> ING• <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> I _ tP_s,.���-«� TITLE <br /> oar <{s <br /> APP!ICANT'S SIGNATURE: <br /> co /v KS ° �' �30 lbs <br /> l 'n� � � <br /> Page 3 ) <br /> EH 23 046 (Revised 4/26/94) <br />