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ENVIRCNHENTAL HE.k.:H DIVISION <br /> ' APPLICATICH FOR UNDERGito= TANK CLOSURE PERMIT <br /> TICK FOR PERMANENT/TEMPCRART CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STCRAGE FACILITY <br /> PERMIT EXPIRES 90 DAYS ]:F APPROVAL. DATE DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW <br /> EMOVAL TEIMPCRART CLOSURE CLOSURE IN PLACE <br /> A SITE # CA Zi�00ZyCONTACT PROTECT NTACT i TELEPHONE rU CL 19L7 Z� D Oo <br /> l'ltLESSY <br /> ITNv VAME JVQ 1/ PHONE f� ��7L/ <br /> D h -�- <br /> ass STREET � <br /> :uHE2/OPERATOR " /YL J C PHONE A <br /> .CHTRACTCR NAME ! �I rn ��(��ij PHONE I <br /> TRACTOR ADDRESS CA LIC tt ( CLASS <br /> USURER R I(,l� A4,r/-,d Y�p6 WORK.CAMP x <br /> E DISTRICT PERMIT i <br /> TORT NAME 1 V rj� wzls � �2Gr[�1' (/ J PHCNE ? <br /> A :IMG FIRM �f'j� G PHCNE 9 C, � Le <br /> I11111IIII <br /> TANK ��� <br /> 1111111111111111 TAN IZE CHEM] S ST RED ENTLY�VIOUSLY DATE UST INSTALLED <br /> u+K� C— <br /> .9- <br /> 9- <br /> IIII111111I11I1IIII[111]1I A <br /> APPROVEITH CONDITIONS) DISAPPROVED <br /> WITH CONDITIONS)LAN REVIEWERS NAME } �-t// ' � DATE11il 11 Il Ill lI III 111111111111111111111111111111111111 1[I II[I]II]l lIl <br /> I WIT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> CUIN CCtXTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN <br /> i <br /> FCRMANCE OF THE =% FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BEOME ; <br /> ECT TO WCR%ER'S COMPENSATION LAWS OF CALIFORMIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> TIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S � <br /> i <br /> SATION LAWS OF CALIFORNIA.• j <br /> I <br /> IS S I GNATLIRE: <br /> " TITLE h DATE 3./a <br /> (Rw 2/8191) ft page 3 ' <br />