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F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />C <br />0 <br />4 <br />T <br />R <br />ENVIRONMENTAL HEALTH DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />ANCE <br />TANK <br />APPLICATION FOR PERMANENT/TEMPORARY <br />TCLOSURE <br />OR ADAND NMDOTNOT WRITE OFIN PLACE UNDERGROUND <br />ANY ESHADED AREAS. NDICATTETPERMIT TTYPE EBELOW: <br />THIS PERMIT EXPIRES 90 DAYS FROM CLOSURE IN PLACE <br />14 OVAL TEMPORARY CLOSURE <br />REM <br />A <br />PROJECT CONTACT & TELEPHONE # <br />EPA SITE # C_' A2�aO0oo Z (f 1S PHONE $ �'ZOGj) �1 K=3 - CD 3 <br />l�S ) <br />FACILITY NAME FjP �'c31 til. *VI ))-I G <br />ADDRESS 1 !o �� L, i -s-e-- r�c� <br />io <br />CROSS STREET ,.-�.�.��y�'� PHONE # 3 <br />�—vim%► <br />OWNER/OPERATOR <br />PHONE # <br />CONTRACTOR NAME `Z L1 c'` Y""_� 'a t= -t <br />LIC # CLASS <br />CA <br />CONTRACTOR ADDRESS I WORK.COMP.# <br />INSURER I PERMIT # <br />C FIRE DISTRICT �� �- � �' PHONE # 0-5) <br />O LABORATORY NAME S(i LAV' %` A�.d-) v Ga- 1 I <br />PHONE # C (•j ► �, 2 r <br />R <br />SAMPLING FIRM <br />illlllllllilillllilllllilillll CHEMICALS SCORED CURRENTLY/PREVIOUSLY DATE UST IrJNS�L; <br />ED <br />TANK SIZE <br />TANK ID a I <br />39- <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39— 11111111111 i1i111flltfilltil111111111111111 IilIII1111111111111t111111111111titllll I1111111111l1i11i111 <br />l 11111111111111111 i DISAPPROVED <br />P APPROVED APPROVED WI CONDNDITION <br />L (SEE ATTACHMENT WITH CONDITIONS) DATE <br />A11111 <br />N PLAN REVIEWERS NAME <br />11111111111111111111 <br />OF <br />OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THN SUCHOAIMANNERIASERTO BECOMETIFY <br />IN <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br />STATE LAWS, AND RULES AND REGULATIONS <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL N07 EMPLOY ANY PE <br />RSON G OR <br />TING <br />GNATURE <br />S THE F <br />SUBJECT CT TO WORKER'S COMPENSATION LAWS OF CALIFORNORAWHICHONHISCPERMITHISIIISSUED, I SHALL CEMPLOY IPERSONS SUBJECT ETO WORKER <br />"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK F <br />COMPENSATION LAWS OF CALIFORNIA." _ (� <br />TITLE <br />k DATE <br />APPLICANT'S SIGNATURE: �Zv' Civ <br />EH 23 046 (Revised 4/26/94) <br />Page 3 <br />