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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM E APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # .PtROJECT CONTACT & TELEPHONE # <br /> F FACILITY NAME � I�Sa,--1 N� - T 1 PHONE # C5l®��33--0578 <br /> A � � { <br /> C ADDRESS 4-o) ,3&--� K£r7��CI A Kj L O� .O <br /> I <br /> L CROSS STREET ,E <br /> I <br /> T OWNER/OPERATOR PHONE # <br /> Y c ® L Q t,� 00:35 — 3342 <br /> C CONTRACTOR NAME S Ot� PHONE #�6l� 2 _ <br /> 0 <br /> N CONTRACTOR ADDRESSCA LIC #�2, S CLASS <br /> T <br /> R INSURER S WORK.COMP.# ® 20 — <br /> A <br /> C FIRE DISTRICT !� PERMIT # <br /> T <br /> 0 LABORATORY NAME K��� At���`(T�CPrI. PHONE # (� 2Cx —1800 <br /> R M l <br /> SAMPLING FIRM � p,{�p �N\jf��' I(Y AL PHONE I��o �Z�— 38 <br /> Illllllllllllllllii�ll Ii� 111( <br /> TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39- i 3-I 2 E <br /> T 39- `"� 2 ' U 3 _ <br /> A 39- lak <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- d-T <br /> 111111 I I I I 1 1 11 I I 11111 I <br /> P <br /> L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br /> A <br /> f <br /> ATTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME �1 - DATE <br /> 11111111111111111111 IIIII <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. v TITLE c DATE <br /> `":�r�iTcv�S:i) �/�� C•,r45[7�C--r �c�� 5'�'rTi��'T�j p/jiL� �E Y'7� �/uvC�✓,�� WiG�iS/� <br /> �r G� At!--- rM7ZC fPc- :r;ij5-r-44,07"r�r� //� K�r�w t 5 f GE <br /> A0oA,,4,lf %� rbc ;,�) -""'J� <br /> EH 23 046 (Revised 4/26/94) Page 3 <br />