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SAN JOAO" N COUNTY PUBLIC HEAt TH SERVICES � <br /> _ E rAONMENTAL HEALTH DIVISIOPOf <br /> .j <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> i� <br /> THIS PERMIT FOR PERMANENTrrFMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGETANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> + 21REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> f <br /> FACILITY INFORMATION it <br /> EPA SITE 4C lfj�j---4 7-LlZ1L-£ PROJECT CONTACT <br />{ FACILITY NAME CPt L � _ �'�~ " PHONE-9 <br /> AD-DRESS <br /> PHQNE# <br /> CROSS STREET <br /> OWNER OPERATOR PHONE# --?el;P_._ 7 <br /> j CONTRACTOR INFORMATION <br /> CONTRACTOR NAMEr _ Orr 'ICJt Cry I PHONE# C <br /> CONTRACTOR ADDRESS C`y �1 S^;I�`^� CA L!C# `.� [} CLASS G <br /> INSURER /A e11f 'ate WORKER COmPi, e-,/6% 17E:,7 <br /> FIRE D1STR1 PERMIT# II <br /> LABORATORY NAME n Ca��+-cp �t COUNTYAbt J✓lEX PHONE <br /> SAMPLING FIRM -� <br /> •!� C.r:���!1c:.G- �J�I1�•—Gv'•LG'�:T`�L PHONE 4&• <br /> i€ <br /> TANK INFORMATION i� <br /> TANK ID# TANK SIZE TANK CONTENTS (PRESENT&I PAST) DATE INSTALLED k <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- it <br /> il <br /> 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 LICENSED AGENT'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 SN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPEN TION LAWS OF CALIFORNIA,- CONTRACTOR'S AIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY.THAArVtTHE PERF RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LIAWS OP CAL_IFOR A." <br /> 1. APPLICANTS SIGNATURETITLE Y- [' T�Zfl i C r'�- DATE.(/ <br /> f <br /> Ij <br /> ❑ APPROVED APPROVED WITH CONDITION,,(S) Cl DISAPPROVED <br /> (SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM d. . DATE1 . <br /> I! <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR AIPPRQVAL PRIOR TO COMMENCING WORK. <br /> CONDITIONS: <br /> 1 59 Nc ^;Ctrl <br /> r Z' -- <br /> d <br /> EH 23 046 rRE'✓ISED 10!19!98) Page 3 <br />