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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE P RMIT TYPE BELOY- i REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE EPA SITE # PROJECT CONTACT & TELEPHONE # � F FACILITY NAME i.�. PHONE # D j A C ADDRESS 4h, V G I L CROSS STREET I - PHONE # T OWNER/OPERATOR Y C CONTRACTOR NAME �� PHONE # N CONTRACTOR ADDRESS 3 �- G d�yL_ CA LIC # v CLASS R INSURER s GsL WORK.COMP.# ( � A C FIRE DISTRICT PERMIT # y , T 0 LABORATORY NAME PHONE # R SAMPLING FIRM PHONE # 11111 i l l l 1111 111111111 I I I11111 A I # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39- T 39- A 39- N 39- K 39- 39- P I111 T L APPV�� APPR D WtT TIONS) DISAPPROVEDq AT T*DITIONS) E N PLAN REVIEWERS NAMDA 11111111111111111111lim IHHII 11111111 111,111 APPLICANT MUST PERFORM ALL WORK\jN CCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE TE cL , EH 23 046 (Revised 7/10/92) Page 3 JUS -j 3 1993 P IERMITIS VICEES TM