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ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />ANCE <br />TANK <br />APPLICATION FOR PERMANENT/TEMPORARY <br />TCLOSURE <br />PRROVALADATE NMDOTNOT WRITE OFIN PLACE UNDERGROUND <br />ANY ESHADED AREAS. NDICATETPERMIT TOTYPE EBELOW: <br />THIS PERMIT EXPIRES 90 DAYS FROM CLOSURE IN PLACE <br />REMOVAL TEMPORARY CLOSURE <br />EpA SITE # AS �QZo�'11.132 PROJECT CONTACT & TELEPHONE <br />C <br />��i Ifv.� X035-ZNN1-i <br />PHONE N '13 - -13 3'7 <br />F FACILITY NAME t,4 am.1- S �S 4- <br />ADDRESS 1 V" • <br />CROSS STREET In�i�Si�ke- I PHONE # <br />OWNER/OPERATORCo <br />f I PHONE <br />I CONTRACTOR NAME�I<'-r� 5 I , ( CLASS <br />LIC # <br />N CONTRACTOR ADDRESS 141 (�. jl id{ � WORK. COMP .# +L 2'jN►-i� n <br />T <br />R I PERMIT # <br />A <br />C FIRE DISTRICT [' I� � '� I PHONE # C510_) to v© <br />T <br />0 LABORATORY NAME v►t��d- QY ' l PHONEb <br /># Lag ZU`�� <br />11 <br />R 1 }� n✓i if�r'+��^�'-°}d'� I T INSTALLED <br />SAMPLING FIRM <br />TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST s z <br />TANK ID #O IAC � [a31�v»-S l S 1 I `L <br />39- <br />T 39- 12 0000 " cl <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- ��� ���� ��� viii» ����� �� iiiii»i�i�iiiiii�iii���iii�iiii�ii� ����f���������>01►ii� <br />P <br />1111111 1 1111'1���� �y/ DISAPPROVED <br />/\ APPROVED WITH CONDITION(S) <br />L APPROVED <br />f ATTACHMENT WITH CONDITIONS) DATE <br />H IAN REVIEWERS NAME <br />P <br />"I CERTIFY THAT IN <br />TY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS <br />OF <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUN <br />HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />THE PERFORMANCE OF <br />WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SAN JOAQUIN COUNTY L <br />THEOF CALIFORNIA." CONTRACTOR'S IC HEALTH SERVICES. OWNER OR LICENSED AGENT' SIGNATURE CERTIFIES THE FOLLOWING: <br />SUBJECT TO WORKER'S COMPENSATION LAWS <br />"I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER <br />COMPENSATION LAWS OF CALIFORNIA." <br />DATE <br />TITLE � <br />APPLICANT'S SIGNATURE: <br />C 5Lo <br />o a <br />Page 3 <br />EN 23 a46 (Revised 4/ /94) 14"d <br />artL&CCe �7 &I, . <br />