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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES g0 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL <br /> ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# r CT CONTACT <br /> FACILITY NAME Jf ue. PHONE# <br /> ADDRESS PHONE# f- <br /> CROSSSTREET IW <br /> OWNER OPERATOR <br /> r� f U P/ ( e' PHONE# <br /> NC70R NAME CONTRACTOR INFORMATION <br /> COTRA <br /> CONTRACTOR ADORESS PHONE# <br /> INSURER CA LIC# Q CLASS <br /> FIRE DISTRICT WORKER COMP# <br /> LASORATORYNAME PERM <br /> SAMPLING FIRM COUNTY PHONE# Q <br /> PHONE # <br /> j TANK INFORMATION <br /> TANK ID# TANK SIZE <br /> I 39 TANK CONTENTS PRESEN78 PAST? <br /> DATEINSTALLED <br /> i 3g_ - <br /> 39- <br /> I 39 _ <br /> 39 <br /> I(+� 39- <br /> I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES-STATE LAWS,FEDERAL LAWS.AND RULES AND <br /> I+ REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING: -I <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 SUBCONTRA <br /> THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS fGSUEO,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFOeRNIA,•J�i� CTWG SIGNATURE SUBJECT <br /> TO <br /> j APPLICANTS SIGNATURE J r�41Glol/Vw•-- <br /> T— TITLE DATE <br /> ❑ APPROVED APPROVED WITH CONDITION <br /> (SE ICONDITIONSBELOW ANDIORON ATTACHMENT) ❑ DISAPPROVED <br /> PLAN REVIEWER'S NAME r�U�' A� <br /> ANY DEVIATIONS FROM O <br /> THIS APPLICATION MOS BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO O 1M N I WORK, <br /> CONDITION(gJ: / <br /> t L'�"�� <br /> EH 23 046(REVISED 06/13)99) Page 3 <br />