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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNIENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THE PERMIT FCR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> EXPIRES ?0 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # er,L Cu) /1 3 9�� PROJECT CONTACT & TELEPHONE # ������ S��TGC� �/� <br /> i 4 <br /> F I FACILITY NAME �ri A� J __��� �.r�� PHONE # I <br /> A O kv }� <br /> ADDRESS -30 <br /> I CROSS STREET VV, <br /> I-f fv,IN( Ro tv <br /> T OWNER/OPERATOR PHONE # <br /> i Y R�1 C �He5-r,4 5��- 7a6oU 719 � <br /> CO CONTRACTOR NAMEEN Q G C, PHONE # _ <br /> TCONTRACTOR ADDRESS O /C A(_ 1?W� CA LIC # �� CJ f CLASS f� / <br /> 6 7- <br /> AINSURER n WORK.COMP.# q 7 <br /> T FIRE DISTRICT j� L PERMIT # aYv�'N� H��yc"Jff ljfoec✓' <br /> 0 LABORATORY NAME COUNTY PHONE #_.&60 <br /> - <br /> I SAMPLING FIRM i f G U PHONE # &,56) i�lo <br /> illllilllllllllllllilllililill <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLD <br /> 39- f" -' O ` C9[9 ,C�/SSC c <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> - III I <br /> 9- <br /> 39- <br /> 39-IIIII111111111 III 1111111 1 111111 I IIIII fill 111111-11-H 1111111111111 111111111111111111111111 llIIII11 IIII111111II <br /> L APPROVED APPROVED WITH CONDITIONS) DISAPPROVED <br /> A E <br /> N E CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> Q <br /> PIAN REVIEWER'S NAME DATE <br /> j03 <br /> I I11111111I I111111111111111111111111111111111111111111111111111111l111111111 IIIIIIIIIIIIIIiilllliilllilillllil111111111111111 <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 TH WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFOi IA." <br /> Q <br /> APPLICANT'S SIGNATURE: c TITLE DATE <br /> ap <br /> CONDITION(S): <br /> �j l '' S��f <br /> EH 23 046 (Revised 9/11/96) Page 3 <br />