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�.S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> r` REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # L o0v, 1 _ ,� PROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME � � (Y (-_:�NTe r PHONE <br /> C ADDRESS k . TOC V�_'R_-)),A �D 0 <br /> I <br /> I CROSS STREET <br /> T OWNER/OPERATOR I PHONE #Q <br /> e� i i�-e Ni o _►..� �� 1 c r v c 0.1 <br /> C CONTRACTOR NAMEPHONE # a <br /> N CONTRACTOR ADDRESSG Ci. Q� �— �,,– CA LIC # ��, CLASS Q'Z <br /> T V <br /> R INSURER '` WORK.COMP.# <br /> A _ v v) 1 <br /> C FIRE DISTRICT PERMIT # <br /> T <br /> 9 v o ci 11g_ r Y � . , ►� <br /> - � ( `�GC,PHONE <br /> 0 LABORATORY NAME C57 � I <br /> R <br /> SAMPLING FIRM CCTc-tT 1 e c iZ.�I 0.nI PHONE <br /> TANK �- <br /> Illllllllllillllllllllil <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- 7– <br /> T <br /> A 39 1 1 <br /> N 39- <br /> K 39 <br /> 39- <br /> 39- <br /> IIIIIIIIIIIIIlI1111111I1111111 III IIIIIIIlllllllllilllllilllll 111111111111111111111111111111111111111 illllllllllllllilllli <br /> P <br /> L APPROVEDAPPROVED WITH CONDITION(S) DISAPPROVED <br /> A (S£E ONDITIDNS BELOW AND/OR ON ATTACHMENT) <br /> N PLAN REVIEWER'S NAME i _�' Z�( �~ DATE <br /> IIIIIIiillillllilillillllllll11111111111111111111111111111 III1111111111111lilllllillllllilllllllllllllllllllllllilllllllllil <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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA." <br /> APPLICANT'S SIGNATURE: 0"u , G u- --!D TITd"i/ 0` �� 1 DATE <br /> CONDITION(S): _ _ �) — <br /> /� lz <br /> r <br /> G� <br /> �)� <br /> �EH 23 046 ( e4j sed 7/10/96) Page 3 //fes <br />