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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 THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />EPA SITE # <br />PROJECT CONTACT 8 TELEPHONE # <br />F <br />FACILITY NAME <br />PHONE # <br />A <br />C <br />ADDRESS <br />I <br />L <br />CROSS STREET <br />I <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />C <br />`p p <br />CONTRACTOR NAME CL S C®N <br />PHONE # O Y- <br />J�� /'fL . <br />N <br />CONTRACTOR ADDRESS <br />qoo ®LD �o <br />CA LIC # <br />Z3 700 <br />CLASS <br />�d �Gzl <br />T <br />R <br />INSURER <br />WORK.COMP.# <br />A <br />C <br />FIRE DISTRICT O Af <br />PERMIT #lr— <br />T <br />0 <br />LABORATORY NAME � i�p LC*,�, 4I ribet 9-RAtc-I D6�- <br />PHONE # Q <br />d <br />R <br />SAMPLING FIRM �/Vt�3 ��,( (�N�/I AO�ifY' 6A)T,/4C.. <br />IIIIIIIIIIIIIIIIIliff111111111 <br />/ <br />PHONE # i�- q2[7 <br />TANK ID # TANK SIZE CHEMICALS STORED <br />CURRENTLY/PREVIOUSLY DATE UST IN T_A}LED <br />39- I [ 0. 01 C�ftSDL iI✓E <br />('R +� wv.I tntJt/j� qy- <br />T <br />39- L 2, a 0 Q A A S P <br />gyp(14 1212 <br />A <br />39- z?_ o00 <br />a-S�� IN,= <br />(ouc.Kln._ <br />!aNIW OV <br />N <br />39- <br />K <br />39- <br />39- <br />1 1 1 �I iiT Tf�i <br />P <br />L <br />1111 <br />_ APPROVED APPROVED WITH CONDITION(S) <br />_ DISAPPROVED <br />ATACHMENT <br />WITH CONDITIONS) <br />X /147 <br />N <br />PLAN REVIEWERS NAME <br />Illlilllllllllllllll <br />DATE Z4 9 �6 <br />lilll <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />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 <br />CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I <br />SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />`-(W <br />APPLICANT'S <br />SIGNATURE: TITLE <br />DATE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />