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0 �'AMe-0 D r,—Q <br />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 />_ZREMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE # oo O O 3 3 PROJECT CONTACT & TELEPHONE # <br />F FACILITY NAME (�v��� STC X02 Q PHONE #(a?6 Y98 - y 9 <br />C ADDRESS C,3 ..? N. -7;o1e V ton <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR PHONE # <br />Y /Y!% /' lir�o74 vii S G <S O 6S 9' - 8500 <br />C CONTRACTOR NAME C \ s : V) c PHONE # y/6) 6S6 -3181 <br />0 a. b o X ;z/ CA LI C # CLASS <br />N CONTRACTOR ADDRESS Pc G n 2 a V G u. , 566 � a a % %s /9 <br />T P, <br />R INSURER G -O 41rh 5 � s WORK.COMP.#NSC -33 8 -06) <br />A _ // <br />C FIRE DISTRICT �' o -k /2 <br />_ �/' trvrn D7 Oh PERMIT # <br />T <br />0 LABORATORY NAME S i0 N PHONE # �U 3 3 0 8 S O <br />R <br />SAMPL I NG F I RM Cam p /i one E PHONE # <br />I11111ltlllTANKlllliitl11111111111ID # TANK Z CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39--j-41LIJ-7 0 1 /b� b O G �/ Iy � Os ASS vti, lN19 8 3 <br />T 39- •-0 " / O •• •' 1 9 8 3 <br />A 39- 1 9 8 3 <br />N 39-___ 1 98 3 <br />K 39 <br />39- <br />39- <br />P <br />L _ APPRO D APPROVED WITH CONDITIONS) DISAPPROVED <br />A / (SEE ATTACHMENT WITH CONDITIONS) G <br />N PLAN REVIEWERS NAME d 1 <br />DATE <br />liiiiiiiiiiiiiiiiiiiiililifillillillI <br />APPLICANT MUST PERFORM ALL WORK IN ACCORD NCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE . OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH T IS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAW CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERF NCE E WORK FOR W THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF I ." <br />A 12 �'4 9� <br />: % ) <br />APPLICANT'S SIGNATU TITLE )? DATE <br />iT < - r, I <br />..3- 6,",.(.,4-rz,�, ✓tel �� v- iv r"Iva . �S M %�' ►^^,,^� <br />J Z zscij 1� ,� h YJ ;'Tv. Ci .J <br />EH 23 046 (Revised 7/10/92) / Page <br />. - li'il, bG jv,n.W ix. V� CaM i W Ck <br />