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• <br />• <br />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 THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />v <br />EH 23 046 (Revised 7/10/92) <br />0 <br />Page 3 <br />is <br />/' REMOVAL <br />TEMPUKAKT GLUSUKt I.LU.IUKC In rLn1.0 <br />EPA SITE # CA C00 3 <br />PROJECT CONTACT & TELEPHONE # <br />F <br />FACILITY NAMEF !�� <br />PHONE <br />A <br />C <br />ADDRESSUJ <br />L <br />CROSS STREET ; <br />I <br />OWNER/OPERATOR > <br />�( <br />PHONE - <br />C <br />Y <br />C <br />CONTRACTOR NAME <br />PHONE # cli1 _ 7�'7 Z--'701 <br />0 <br />N <br />CONTRACTOR ADDRESS O <br />CA LIC # <br />CLASS <br />R <br />INSURER r1l <br />r'C rt <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICTU ` <br />PERMIT # <br />T <br />0 <br />LABORATORY NAME �,L <br />PHONE # <br />R <br />\ <br />SAMPLING FIRM <br />PHONE #C� r� <br />TANK ID # <br />TANK SIZE <br />CHEMICALS STORED CURRENTLY/PREVIOUSLY <br />DATE UST INSTALLED <br />39- 1 --G o <br />i 000 <br />T <br />39- H ZF A Tr <br />A <br />39- )'/2f- oci <br />Tr <br />r, <br />N <br />39- I Y t <br />RIP I -'r -r' <br />K <br />39- <br />39--- <br />39- <br />P <br />L <br />APPROVED <br />APPROVED WITH CONDITION(S) , DISAPPROVED <br />A <br />E A TA ENT WITH CONDITIONS) <br />-53 <br />N <br />PLAN REVIEWERS NAME <br />DATE <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 AGENTS 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 <br />FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF NIA." <br />�1 <br />TITLE ��' f?J� �) it / /1w �c,AATE 1 <br />APPLICANT'S SIGNATURE: r p <br />i. <br />EH 23 046 (Revised 7/10/92) <br />0 <br />Page 3 <br />is <br />