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v <br />ENVIRONMENTAL HFALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />xrrLImm{nn FOR rERMANEHTtT ARY CLOSURE OR ABANDONMENT IN rLxcs or ouncxoxmmo xxzxx000x nmxmxcs m/onocc /xxx <br />THIS DAYS FROM PPROVAL DATE. on NOT vn/rc /N ANY nmmpn xocxs. /xn/cxrp pcxxr/ npc ocLnm: <br />epnmmr� rsnpnnxnr cLnSuns cLosonF IN pLxcs <br />Ell 23 046 (Revised 7/10/92) pngo! 3 <br />�� <br />�� �� <br />�� <br />EPA SIT <br />PROJECT CONTACT TELEPHONE N <br />C <br />ADDRESS <br />VA - <br />L <br />CROSS STREET <br />0 <br />LABORATORY HAM <br />PHONE 0 <br />ID <br />TANK SIZE CHEMICALS,STORED CURRENTLY/PREVIOUSLY DATE LIST I TALLED <br />K <br />39- <br />L <br />PIIROVLD <br />PPROVED <br />APPROVED W IT <br />APPROVED W IT CONDITION(S) DISAPPROVED <br />A <br />(SEE AT <br />(SEE ATT HE WIT" CONDITIONS) <br />"WIAN <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE <br />A CC <br />ORDA CIE IN S JOAOUIT <br />WITH SAN JCAOUI COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />THE PERFORMANCE OF THE WORK FOR WHICH <br />OWNER OR LICENS ACENTIS SIGNAIURF CERTIFIES THE FOLLOWING.* "I CERTIFY THAT IN <br />THIS PERMIT IS ISSUED ' I SHALL NOT EMPI.GY ANY PERSON IN SUCH A MANNER AS TO BEC"IF <br />SUBJECT TO VORKER'S COMPENSATION LAWS <br />or CALIFORNIA." CONTRACTOR'S HIRING JCR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING! <br />"I CERTIFY THAT IN THE PERFOR14AIlCE OF <br />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 <br />TITLE DATE <br />Ell 23 046 (Revised 7/10/92) pngo! 3 <br />�� <br />�� �� <br />�� <br />