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ENVIRONMENTAL HEALTH DIVISION lc <br />l k " ; 9 <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT,' �9�i,J <br />APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARI)0615Nt&p1N�-S-TORAGE TANK <br />E <br />THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICA PE W-TYPEBEELOOW�:I <br />REMOVAL TEMPORARY CLOSURE CLOSUREMP NAPKITA 496--,) <br />EH 23 046 (Revised 4/26/94) 0 � � rr r Page 3� <br />EPA SITE # II 9says�a 3 <br />� <br />PERM V&LI - <br />PROJECT CONTACT & TELEPHONE # 1-06k1-06kf4ollmctn Ir%+'� <br />F <br />FACILITY NAME L•1 �5 5 <br />PHONE -f 73_ 733'? <br />'lOC�/ <br />cQDct <br />A <br />C <br />ADDRESS �7D1 !iY?arc� L.ar °e 'oc, n <A <br />45ai q <br />I <br />L <br />CROSS STREET S <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />/'_ <br />C <br />CONTRACTOR NAME?bet/b/9 I �,�' .15 <br />PHONE # ��.� ..$ <br />` <br />0 <br />N <br />CONTRACTOR ADDRESS <br />17)q#,j6t4 AlrY <br />CA LIC # 4095787 <br />CLASS A <br />/Tt'9/U. •C,;-�e5 <br />` <br />T <br />R <br />INSURER ; <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT C <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME rI A Q / <br />PHONE # 5�D//�yy©©Q% .��. <br />R <br />SAMPLING FIRM <br />PHONE PHONE # 1 ��g©©���� <br />[ , `I. 32 -..-1S .,� <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />- <br />39aA <br />3 <br />39- ) t n <br />A <br />39- <br />_ <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />iiiiiiiiiiiiiiiiiiiiiiiiiiiii <br />L <br />APPROyD APPROVED WITH CONDITION(S) <br />5D <br />DISAPPROVED <br />A <br />_ <br />/ /" (ATTACHMENT WITH CONDITIONS) <br />DATE'"� T <br />N <br />PLAN REVIEWERS NAME /J <br />1111111111111innimminfill 1-1111111111111111111111 MUMMMM <br />I I I I 111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br />ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S <br />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 COM SAT ION WS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I <br />CERTIFY THAT IN THE E A F THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CA F N .' <br />APPLICANT'S SIGNATURE: <br />TITLE DATE 0 <br />EH 23 046 (Revised 4/26/94) 0 � � rr r Page 3� <br />