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a <br /> k <br /> JAN 2 8 1993 � <br /> AONMENTgL <br /> HERMIT/SERVICESi <br /> ENVIRONMENTAL HEALTH OIVI ION <br /> APPLICATION FOR UNDERGROUND STORAGE TA41C 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 /> L- REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> PROJECT CONTACT i TELEPHONE i V ff <br /> EPA SITE # 1. � i <br /> F FACILITY NAMEM O <br /> fyl,LLr PHONE # Co y <br /> t_ <br /> A - <br /> C ADDRESS Z-961 <br /> L CROSS STREET R L <br /> T OWNER/OPERATOR PHONE <br /> T _ <br /> C CONTRACTOR NAME 1 v PHONE # Za <br /> 0 <br /> N CONTRACTOR ADDRESS LC. � LIC tlG' <br /> C_1?(Q� CLASSL� <br /> r <br /> R INSURE A, WORK.COMP.# <br /> A <br /> C FIRE DfSTRiCTC i C .�K T 2 PERMIT # <br /> T <br /> 0 LABORATORY NAME C - PHONE <br /> R <br /> SAMPLING FIRMPHONE # <br /> 1[[11[I1111111111I111l11!!IlII �` �` <br /> ANK 10 # TANK SIZE CHEM CAL TORED CURR9N7LY/PREVIOUSLY DATE UST INSTALLED <br /> T 39- <br /> A 39- <br /> N 39- <br /> K 39- <br /> 39- <br /> 39- <br /> P 11lI <br /> L APPROVED APPROVED WITH CDNDIT ON(S)t � DISAPPROVED <br /> EE ATTACHMENT WITH t011D TIONS) C_ C <br /> H PLAN REVIEWERS NAME ! DATE a � ! <br /> 1[illllllll1111111lIIII1111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY OtOIRANCES, STATE LAMS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S S GNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 13 ISSUED, I SHALL NO EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO VORKER'S COMPENSATION �LIFORNIA.• CONTRACTOR'S HIR NG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE ERF OF E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CA f IA -� <br /> l .,, O <br /> APPLICANT'S SIGNATURE. �f TIT t>r DATE -Z — <br /> L <br /> S �;1C,- . <br /> (Revised 7/10/92) P8941 3 <br />