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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 x L:A2O00000 L S PROJECT CONTACT & TELEPHONE -9 �� �o1)r,tu., �q►(o)fo35-Zl Lk <br />FACILITY NAME t' J ) ),q G PHONE <br />ADDRESS <br />CROSS STREET ' y `o �y }.{� CS <br />OWNER/OPERATOR <br />CONTRACTOR NAME C.=i 4) -e,— _ <br />CONTRACTOR ADDRESS (�'� L_4--7 <br />INSURER <br />FIRE DISTRICT <br />LABORATORY NAME <br />�w�-- f�►!"'�d--� ✓y -t I Gal - <br />PHONE I c �� _Q� & 1 <br />PHONE 0 5 I p) <br />CA LIC x Z2-O-1Gi3 + CLASS A-, -D q <br />WORK. COMP WCf� SOG-7-1-11 3 <br />PERMIT ;* <br />PHONE CO 00 <br />SAMPLING FIRM (T I I PHONE T (I•j 1 Oj Zt7/v — g re -49 <br />1111111I11i111t11111I1If111111 TANK SIZE CHEMICALS 570 <br />39_ <br />RED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />TANK ID <br />5�0 C t.✓ of � _yn Lr'+r�w:-� <br />T 39- <br />A 39- j <br />N 39- i <br />K 39- <br />39- <br />39- <br />- <br />9- 1 <br />39-1111111111111111 1t11t 111 1111111 <br />11111 11 11111 111 t 1 1111111111 1i11111I1111111t1I1 <br />P <br />L _ APPROVED APPROVED WITH CONDITION(S) _ DISAPPROVED <br />A E= ATTACHMENT WITH CONDITIONS) DATE "6161 <br />N PLAN REVIEWERS NAM IIIII <br />11111111111111111111 <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOACUIN COUNTY ORDINANCES, STATE LAWS, AND RUL_S AND REGULATIONS OF <br />SAN JOAOUIN 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 />"I CERTTO IFY TTHHATERINSTHEE PERFOTION LAWS OF R14ANCE OF THE WORKOFORAWHICH THIS PERMITHISING OR ISSUED�B�ALLCTING SIGNATURE EMPLOY PERSONS SUBJECTETOTHERKR'S FOLLOWING: <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE ��G ✓i� +' OAT. -I <br />l LivX��-r <br />EH 23 046 (Revised 4/26/94) Page 3 <br />Cr <br />