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PAYMENT <br /> RECEIVED <br /> J U N 0 3 1333 <br /> SAN JOAQUIN CCII_iNTY <br /> ENVIRONMENTAL HEALTH DIVISION PUBLIC HEALTH SE14VICES <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT ENVIRONMENTAL HEALTH DIVISION <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 /> X REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br /> EPA SITE # <?,-q-) 000L �3 PROJECT CONTACT & TELEPHONE # j $tj W - IT)Cr�i:v(o,2_ae-=,owp <br /> F FACILITY NAME Q { PHONE # Z� qC;-7 24[t6_7 <br /> A <br /> C ADDRESS ��10(pt'H��,�RApp '� ! .OGK.�� <br /> I <br /> L CROSS STREET I-}jS,MM 1�A1��C <br /> I <br /> T OWNER/OPERATOR �(Q� �.P.�►17✓G�j �jypo,�y )iONE #Q� ✓'�'��'� <br /> Y <br /> C CONTRACTOR NAME -t����i�,� try,, ©F ��E � PHONE #o <br /> N CONTRACTOR ADDRESS 2:3,,C>(o-j CA LIC # (¢j�jCjl=j() CLASS <br /> TWORK.COMP.# fwL Z(j'77j-7-:�, <br /> R INSURER G�cVIT1 »7Aa--jLz7 Ins'. GG. <br /> A <br /> C FIRE DISTRICT jjr-tJW4 POESF-r. PERMIT # <br /> 0 LABORATORY NAME �"12�Z( �►.1U �p1.1►�I�F.?� rt� l,A,13 (� PHONE # q((p•(p'�� ' (02 <br /> R a�14'l�i <br /> SAMPLING FIRM E3'1�3V1{�A�llt� - Lmi;, i rv. PHONE # -11L, -f 3S- ?Gg4p Z <br /> I Illilttillllliillliilillllltl <br /> Tq ID #� TANK SIZE CHEMICALS STORED Y DATE�� INSTALLED <br /> 39- <br /> T 39- Lllh <br /> A 39- <br /> N 39- — NE <br /> K 39- <br /> 39- <br /> 1111 «Lin <br /> P <br /> L APPROVED APPROVED WITH CONDITIONS) _ DISAPPROVED <br /> A (SEE TTACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAME DATE �J <br /> 1111111IIIIIIIIIIltt III IIIIIIIIII 1III ifIII I111111ffT IIIIITfII <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 WHICH 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 1N THE PERFORMANCE OF T WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br /> COMPENSATION LAWS OF CALIFORNI ." <br /> t <br /> APPLICANT'S SIGNATURE: TITLE A14407 1WAee&7 DATE <br /> li 1411,0M w, 01i47SPAI rf/ 33Z- soilp,4 <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />