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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 />iC REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE 0,&0p2 PROJECT CONTACT & TELEPHONE # L-jb" <br />F FACILITY NAME �'�lG PHONE # <br />A <br />C ADDRESS -� <br />1 <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR PHONE # <br />C CONTRACTOR NAME A4 --w P4, 1 PHONE # Gj�, ?� St1jeOC7 <br />0 <br />N CONTRACTOR ADDRESS CA LiC # CLASSa <br />T <br />R INSURER WORK.COMP.# <br />A <br />C FIRE DISTRICTPERMIT # <br />T <br />0 LABORATORY NAME a�-aa'PHONE # G✓(D, �j-72 , CDU <br />R SAMPLING FIRM `i1-TC$iZ ON � "rGC.4MVt_e,& ` t�La 'PHONE # <br />TANK ID # YANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY OATS UST INSTALLED <br />39• l _ 2.tDb0 _ 17M GL f IN N <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P <br />L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A R (SEE ATTACHMENT WITH CONDITIONS) <br />N PLAN REVIEWERS NAME _ ® DATE {= <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 WHICR 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, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: ITLE 2Z4 O t G INCL C 7'�DATE <br />EH 23 046 (Revised 7/10/92) Page 3 <br />