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ENVIRONMENTAL HEALTH DIVISION <br />i <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 # NON�i <br />PROJECT CONTACT & TELEPHONE #---r--, <br />F <br />A <br />FACILITY NAME— nVnC <br />PHONE # 2!oq- <br />i <br />ADDRESS 71=illi� �JT-lz r2 I POO <br />L <br />I <br />CROSS STREET <br />L/� 6 � (79 <br />T <br />OWNER/OPERATOR <br />PHONE # <br />Y <br />- ' ( n'! <br />// <br />S16 6 s: - <br />C <br />0 <br />CONTRACTOR NAME 'Ckjt�o — /�1 Lr71. <br />PHONE ~7 ,. Z� <br />NCONTRACTOR <br />T <br />ADDRESS hC _ CO UIZi' �,� CA LIC # 7n <br />CLASS <br />R <br />A <br />INSURER �,j f'1Il <br />WORK.COMP.# <br />C <br />FIRE DISTRICT <br />PERMIT # <br />T <br />0 <br />R <br />LABORATORY NAME U 0 1 Pt Ai,\l �^ �A7 — I <br />PHONE '�� — 9� <br />SAMPLING FIRM FvisRO LI)l:-:%Z-X#-C, 6 D PuLb--AJ PHONE <br />Iillllllllllllllllllllllllllli <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />, <br />® <br />39- ! - <br />VN IawlKlur. i.l <br />T <br />39- <br />AJ <br />L <br />u)�-)&Z <br />A <br />39- <br />C�A�t , ti ;y <br />s2 un g <br />UA71Cn z) 3 <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P <br />111111 II 1 1 <br />I I I it IIIIII <br />L <br />_ APPROVED _ APPROVED WITH CONDITIONS) _ <br />DISAPPROVED <br />A <br />(SEE ATTACHMENT WITH CONDITIONS) <br />N <br />PLAN REVIEWERS NAME <br />Ilillllllllllllillll <br />DATE <br />11111 <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 <br />EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE <br />TE <br />EH 23 046 (Revised 4/26/94) Page 3 <br />