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A. � �' /�t`n>� � � �► <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 # O p O 3 3 PROJECT CONTACT & TELEPHONE # m�� �� C ) 3 413 <br />— S <br />F FACILITY NAME Qvll lO 15.16 _f' /oi 19 PHONE #leab 4/;p8 <br />C ADDRESS / 3 a �U4 d <br />1 <br />L CROSS STREET <br />I <br />T OWNER/OPERATOR PHONE # <br />Y m /C ovii S r G <.S O 6 S 9- — 8 5- <br />C CONTRACTOR NAME C s C PHONE # � IAO 655 -3/ 81 <br />0 0. i�iO X 7Z/ $ CA LIC # CLASS <br />N CONTRACTOR ADDRESS PP 1 2 d G a S6" a a 9 ys /� �- <br />R INSURER &o Idle 17 A -9Q G � S • WORK. COMP.#NSC '33 8 ^ b0 <br />A <br />C FIRE DISTRICT I o ?c G _ / �� �s'UCh Or PERMIT # <br />r_ <br />0 LABORATORY NAME Sv10c /p i2 N /� PHONE* (SSU .3 3— 085-0 <br />zzR <br />SAMPL I NG FI RM C 6 rn p I%4/JG 5,n GloS ,/LL j Z n C . �-!I/' In A PHONE # (S/O 5'.? 6 - 5_3 9S <br />TANK <br />IIII11111111111111111111 <br />TANK iD # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- )'L I �, I /b, b o o . '/ to Co 14183 <br />T 39- /O d " " 1 9 93 <br />A 39- ,x, 8' o e o �. `` 1 9 8 3 <br />N 39 _ -- o 0 0 �� s 1�cL_-. 1 9 S 3 <br />K 39- <br />39- <br />39. <br />i I i I MTf ff (�[iT�f fTiTl Tf1TTT �111TffffilRTffff�n <br />P <br />L APPROVEDAPPROVED WITH CONDITION(S) <br />_ DISAPPROVED <br />N PLAN REVIEWERS NAME �/ (SEE AT CHMENT WiTH CONDITIONS) <br />TE <br />DA <br />11111111111111111111 TiiIiTiTt�illlTTTiTTiTiT1�i11TiTlTiTTi11TiTTTt111I I IcI11iT 1TITiT11TT <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, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO WORKER'S COMPENSATION LAWn CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY THAT IN THE PERF NCE T E WORK FOR W THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIF I ." ,v A �o4 0-r- (� �) <br />APPLICANT'S SIGNATU TITLE DATE <br />7,,,�'�— <br />EN 23 046 (Revised f/1oi ®� er %�� v'ti ' Z'Pe/�e 3e, t,l ec,l <br />v /`''1�•� t��K- 'Yv�^M �" � V`. (,t'�`;� te-u `� O` `7Q" <br />JJa c. c� ted? cg ot,:5,.i END <br />'�v� l� <br />