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SAN JOP )IN COUNTY PUBLIC HEALTH SEr-ACES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTI EMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> �( REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT G.� _ - /G' PHONE# —J ' <br /> FACILITY NAME PHONE# <br /> ADDRESS F e <br /> CROSS STREET <br /> OWNER OPERATOR 0 C- �,( -> �' aT PHONE* <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME IPHONE At <br /> CONTRACTOR ADDRESS 0 C?C _ CA LIC* - / ry - CLASS <br /> INSURER /4 T w WORKER COMP# <br /> FIRE DISTRICTDI�nH PERMIT# <br /> LABORATORY NAMEC COUNTY PHONE <br /> SAMPLING FIRM z4�zN PHONE 'q <br /> TANK INFORMATION <br /> TANK ID At TANK SIZE TANK CONTENTS(PRES NT& PAST) DATE INSTALLED <br /> 39- 7 <br /> 39- <br /> 39- <br /> 39- <br /> 39- <br /> 39- <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 CCENSED AGENTS 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 /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT I PERFC 0 NCE E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LA IF RNIA.' <br /> APPLICANTS SIGNATURE ITLE �•�' -�� !.�^-( DA '� g <br /> ❑ APPROVED CkAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> n <br /> PLAN REVIEWER'S NAME , O [,.57�� DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br /> COypITIONS: - <br /> l �Qo <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />