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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL1 DIVISION <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THE PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br />EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br />REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />EPA SITE # (fAD p 0 <br />PROJECT CONTACT & TELEPHONE #Al ?i S s2 -7y76 <br />F <br />FACILITY NAME )='j <br />PHONE # zoq— <br />A <br />C <br />ADDRESS 090 PICC / <br />I <br />L <br />CROSS STREET <br />o <br />I <br />T <br />Y <br />OWNER/OPERATOR t �� PHONE # <br />C�����/2S 2� 7Z --2;-7V74 `C <br />C <br />CONTRACTOR NAME (Jf�( CfrtC /V�// PHONE # <br />0 <br />N <br />CONTRACTOR ADDRESS �� � �` �g 7�r �` ��S- C4 <br />CA LIC # ��j� g <br />1 <br />CLASS <br />T <br />R <br />INSURER E® rjf}�e e/ t a �® WORK.COMP.# utJG Ll7 f -760S- <br />A <br />C <br />FIRE DISTRICT PERMIT # <br />T <br />0 <br />LABORATORY NAME <br />COUNTY PHONE # <br />R <br />SAMPLING FIRM PHONE # <br />111111111111111111111111111111 <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- _si <br />T <br />39- <br />I r, <br />A <br />39- <br />N <br />39- <br />K <br />39- <br />39- <br />39- <br />P 1111 111111 1 1 1 I 111111 1 I! III I 1111 <br />L APPROVED _ APPROVED WITH CONDITIONS) _ DISAPPROVED <br />A (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />N t <br />PLAN REVIEWER'S NAME DATE 'y <br />II111111111111111111111111111111111111111111111111 IIIIII1111111111111111111111111111111111111111111111111111111111111111111 <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 IN THE PERFORMANCE OF THE RK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE 1DATE <br />CONDITION(S): <br />EH 23 046 (Revised 9/11/96) Page 3 <br />