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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH 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 A N PLACE <br />EPA SITE #-CA-f6j 02���-� PROJECT CONTACT & TELEPHONE <br />F FACILITY NAME-�GIflG"� y PHONE # /fj�� ►�T�� <br />A <br />C ADDRESS <br />I �� ��r Jam( ���� �. <br />✓�� <br />L CROSS STREET <br />I <br />Y OWNER/OPERATOR � , PHONE L'II � (p q-41� <br />CONTRACTOR NAMEK\/eV? - t t4QO 1 t4 PHONE # <br />N CONTRACTOR ADDRESSCp(,01 A F rA �9CA LIC # O CLASSA/pjt G�-PSD G� <br />T <br />R INSURER WORK.COMP.# <br />A <br />C FIRE DISTRICT PERMIT # <br />T LABORATORY NAME COUNTY G(f �}� PHONE # 10 <br />Ql1t"T ?;-40-1100 <br />SAMPLING FIRM j.�'��j�� �I.CI � PHONE 0— 9110 <br />lillfillllll11111^1�l1111111 I! 1 <br />39- TANK ID <br /># _� TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />T 39- <br />A 39- <br />N 39- <br />K 39- <br />39- <br />39- <br />P IIII11111111 Milli IIIII 1i !I!I! II1111111 1 11 1 11111i1f1 1 111111!!11 !II 11111111111111111 <br />L _ APPROVED OVED WITH CONDITIONS) DISAPPROVED <br />A (SEE ITIONS BELOW AND/OR ON ATTACHMENT) <br />N <br />PLAN REVIEWE S NA �� DATE G �- <br />1111111111l11111 1111111lI1111111111l11 11 11111I1111111111111lIIlililllllllllilif11111111111fllilillllllfllillllllllill! <br />APPLICANT MUST P RFORM ALL WORK IN ACCORD WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br />SAN JOAQUIN C TY PUBLIC HEALTH SERVICE OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMAN OF THE WORK FOR WHICH T PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br />SUBJECT TO KER'S COMPENSATION LAW CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br />"I CERTIFY AT IN THE PERFORMANCE 0 E WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CAL NIA." <br />APPLICANT'S SIGNATURE: 12, TITLE G DATE i 4 <br />L� <br />CONDITIONS): <br />�✓ <br />EH 23 046 (Revised 9/4;796) lka../'Page 3 <br />