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j�. <br /> SAN JOAQ IN COUNTY PUBLIC HEALTH StWICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGEITANK CLOSURE PERMIT <br /> II <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL Cl TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION It . <br /> EPA SITE# PROJECT CONTACT %t M J I r J, +, PHONE# <br /> HONE# �j SZ Y-5 66 3 <br /> FACILITY NAME C E-{ - STD sk C•, <br /> ADDRESS e- I <br /> CROSS STREET C r- -e--e- L Com- — 1�. <br /> OWNER OPERATOR I fI]/1 14 SIG�fI Pfd PHONE <br /> I� <br /> CONTRACTOR INFORMATION <br /> i <br /> CONTRACTOR NAME SEMOO ,� PHON E# 209-524-9653 <br /> CONTRACTOR ADDRESS 1217 South 7th Street C4 LIC# 449864 CLASS 1 A HAZ <br /> INSURER State Fund Insurance Company WORKER COMP# 007108-98 ASB CS <br /> i FIRE DISTRICT PERMIT# <br /> LABORATORY NAME -fl-16_7W+N F _ [4(3112 A-r021 c s COUNTY {Vj, 1 PHONE# cl to �d a r <br /> E SAMPLING FIRM M(k[ PHONE ?,,Cel} S - {$ <br /> TANK INFORMATION i <br /> TANK ID# TANK SIZE TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39- IL 1 Z 000 <br /> 39- r <br /> 39- <br /> 39'- <br /> 39- <br /> 39- <br /> APPLICANT <br /> 9- <br /> 39_39-39-APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSEDIAGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I <br /> 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 <br /> O <br /> 70 BECOME SUBJECT T WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S'HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 't CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIF RN ,It <br /> APPLICANTS SIGNATURE TITLE3r + 9 O��C�' DATE <br /> ❑ APPROVED XAPPROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> .PLAN REVIEWER'S NAME <br /> '} DATE� � <br /> ANY DEVIATIONS FROM:THIS APPUCATION MUST 4E IUBMITTED TO EMD FOR'APPROVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS <br /> i r�- <br /> k IJ v <br /> a <br /> ij <br /> EH 23 046(REVISED 10149198) Page 3 <br /> 13 <br />