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ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR AZANDON14ENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: or REMOVAL TEMPORARY CLOSURE CLOSURE IN PLACE EH 23 046 (Revised 7/10/92) Page 3 EPA SITE # (((o J :TLp PROJECT CONTACT & TELEPHONE # F FACILITY NAME PHONE z6 as. A C ADDRESS C1i S I L CROSS STREET I T OWNER/OPERATOR PHONE # Z C O CONTRACTOR NAMEPHONE ui # O _ L� 5 -3 V N CONTRACTOR ADDRESS _ CA LIC # S CLASS A _ N rA'- T R INSURER L� 8 `� WORK.COMP.# & WC A C FIRE DISTRICT _ PERMIT 7 0 LABORATORY NAME ` PHONE #�_02 R SAMPLING FIRM TANK ID # _ PHONE # c�-6 LCL TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED 39 - T 39- t �Lr)n jjd 4-e4WA4A 9 li! A 39- N 39- K 39- 39- 39- P "�' L APPROVED ell APPROVED WITH CONDITION(S) _ DISAPPROVED A _ ^ (S ATTAC NT WITH CONDITIONS) N PLAN REVIEWERS NAME 1111 fill I DATE ! ( cp APPLICANT MUST PERFORM ALL IN AC AN ETN SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." APPLICANT'S SIGNATURE: TITLE C0 VO CO L, bf DATE 5 EH 23 046 (Revised 7/10/92) Page 3