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� N. -.t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL Q TEMPORARY CLOSURE 0 CLOSURE'IN PLACE rAC ne, T -j�3 (7 FACILITY INFORMATION EPA 5RE'. .U�' OJECT CONTACT PHONEQ s s 39- PHONE R FACILITY NAMEDDRES A AS �~ CROSSSTR T W _ is Ytiiiw PHONE a OWNER OPERATOR d t...- TANK INFORMATION CONTRACTOR INFORMATION 39. — w 39- PHONE Y CONTRACTOR NAME S+__ -� 39- CONTRACT R ADDRESS INSURE LIrL� - WORKER COMPF A FIRE DISTRICT PERMIT B PHONEM LAB ORATORY NAME COUNTY SAMPLINGFIRM PHONE M TANK INFORMATION TANK 10 F7TANK TANK CONTENTS PRESENT d PAST DATE INSTALLED 39. — w 39- 39- 39- 39- 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWWO 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.) SMALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO YECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING'. '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERY' T IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA' APPLICANT'S SIGNATURE TITLE &a 4r D�Vfe, I4" DATE ❑ DISAPPROVED " - 1-� ( E ONOITIDNS BELOW ANOJOR ON ATTACH I PLAN REVIEWER'S NAME, ANY DEVIATIONS FROM THIS APPLICATION MUST BOONDITIONgHD FOR APPROVAL