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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 />lir REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE <br />EPA SITE #CSC 0C?1 �(P� S eo PROJECT CONTACT & TELEPHONE # c.>vt- ss& <br />F FACILITY NAME PHONE 26 , <br />A <br />C ADDRESS (�S <br />I <br />L CROSS STREET <br />T OWNER/OPERATOR pl C=k PHONE # <br />Y Sulvi (Z -021 -IG --3--S(z) <br />C CONTRACTOR NAME PHONE # O <br />0 <br />N CONTRACTOR ADDRESS W �� CA LIC #3� S CLASS A _ <br />T _1 <br />R INSURER `U WORK. COMP. # (� LCC 3 19 10 ob <br />A <br />C FIRE DISTRICT PERMIT # <br />T <br />0 LABORATORY NAME` PHONE # ��c' <br />R _ <br />SAMPLING FIRM �ZD v� y {�C PHONE # �� S Z - b oc <br />liiiiiiiiiiiiiiiiiiiiriiiiiiiirlI <br />TANK ID # TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br />39- "' <br />T 39- /� [1 n 4- <br />A 39- <br />H 39- <br />K 39- <br />39- <br />39- <br />P <br />L _ APPROVED X APPROVED WITH CONDITIONS) DISAPPROVED <br />A (SEE TTACH T WITH CONDITIONS) / <br />N PLAN REVIEWERS NAME DATE <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE TH SAN JOAGUIN 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S <br />COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE: TITLE O Dyo ca l� f DATE S <br />EH 23 046 (Revised 7/10/92) Page 3 <br />