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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. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE 9 (_AQ 000000 Z [.o S I PROJECT CONTACT & TELEPHONE �U Mo I � ^ �Q 1 L,) fo35—Zj+4.6+ <br />FACILITY NAME 1 ) Q PHONE 1 CZ�4� �j $3 - -38 1 <br />- � }5c3.C�1 � � � i -- <br />ADDRESS <br />CROSS STREET <br />OWNER/OPERATOR <br />aLSsP.r a-� ►�3r+ <br />CONTRACTOR NAME i <br />CONTRACTOR ADDRESS 6 1 U <br />PHONE 1 <br />PHONE ;o 5 1 U, 5 5 1- Z; <br />CA LIC x 20 '1 41 3 CLASS A, _D N to Cr <br />WORK. COMP . hiC OU 7 '7 1 3 1- r>4z <br />INSURER T1 �Y -.c <br />FIRE DISTRICTt�r^r1•�1.a� t�.tY��fj I PERMIT <br />3 + LABORATORY NAME PHONE 00 <br />LOQ �I �� Co <br />i I SAMPLING FIRM T 111 <br />I PHONE C G I O-) 'Z �/o - g� 4f J? <br />11111lilllllltt1111111111[1111 T I CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANK ID tt 1 <br />39- 550 4./d�s��. o�yr• Lnvy:-, <br />T 39- <br />A 39- I <br />N 39- <br />K 39- <br />39- <br />39- <br />I1111 11 l 1 111 ll 1 fill 1! 1 ll 1 11 1 11 1! 111 1 1 l !!ll! llillllllllltll!!ll! 11 III 1 1! 111 I! <br />P <br />APPROVED APPROVED WITH CDNOITION(S) _ DISAPPROVED <br />A �— SEE ATTACHMENT WITH CONDITIONS) <br />:�lp zsj/w) <br />N PLAN REVIEWERS NAMOL DATE <br />[ililllllt1t11111111 HIIIIIIIIIII III 1111111111111111111111 <br />lllll <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDNCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />TSAN jOAQUIN HE PERFORMANCENTY OF HELIC WORKEFORHWHIICCHITTHHIS PES. RMIT IER SS ISSUED, IAGENT'S <br />NOTSIGNATURE <br />EMPLOY ANYCERTIFIES <br />PERSONTHE <br />IN SUCHOAIMANNERIASTOIFY BECOME <br />THAT <br />IN <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 70 WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." /^ <br />APPLICANT'S SIGNATURE: L►�tc— TITLED-+��►"�� "t'�✓- DATe3-Z-�7 <br />EH 23 046 (Revised 4/26/94) Page 3 <br />