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w <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # <br />PROJECT CONTACT & TELEPHONE <br />F <br />FACILITY NAME J 7 <br />PHONE #(Z®q - % 7 <br />I <br />A <br />C <br />ADDRESS 17 AV-=- k4A1VrlS4cA <br />e <br />I <br />L <br />CROSS STREET <br />I <br />TY <br />OWNER/OPERATOR Ta k, r®w ® PHONE #r ®� <br />® <br />C <br />CONTRACTOR NAMEA L Al 7" Z- PHONE # r <br />8&86p <br />i <br />0 <br />N <br />T <br />CONTRACTOR ADDRESS A M . A41t plr44 <br />CA LIC # 7 <br />CLASS G IV e <br />R <br />INSURERr-flu` i,il 1 WORK.COMP.# '12 <br />A <br />C <br />FIRE DISTRICT PERMIT # <br />T <br />0 <br />R <br />LABORATORY NAME ®i6. <br />COUNTY o. PHONE # C*1 q gS <br />— <br />SAMPLING FIRM (4,t -% L -« PHONE #Cy6,pz,«.C�,t® <br />lllllllllllllllillll 111111111 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- <br />T <br />39- <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />1111l1I1111111I1 1111111111111 11111111111111111111111111111111 ullllIlll IIll IIIIIIIIIIIIIIIIIIIIIi 1u1111fill u11111111 <br />P <br />L APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED <br />_ <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWER'S NAME DATE <br />1111111 III I I II I Ill ll1i1111111111111Iliilill lllllllllllllllllll1111111litllllilllllllllllllllll lllifl111111111111III I III I I III I <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: -✓'^' TITLE �' ""C® DATE 1AIZIS <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />