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VIRONMENTAL HEALTH DEPARTh' IT APPLICATION Fbl' UNDERGROUND STORAGE TANK -CLOSURE PERMIT THIS PERMIT FOR PERMANENTREMPORARY 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: ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY CROINANCES, STATE LAM, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY EN\nRCNMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THISPERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORNEt3 - - OF .• APPLICANTS SIGNATURE � =.`COKITRACTOR INFID MMON TANK ID # I TANK SIZE y(a50 EPA SITE PROJECTCONTACT Melv;n KH'-rw n PHONE# 33(. 9060 FACILITY NAME R Sk_: ADDRESS 351 C er-Y-mPn_ �A L ADDRESS I Z L S CLASS A Hwt L o CROSS STREET 941E 4J re -EcS+ Wp OWNER OPERATOR ?qn S K PHONE # APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY CROINANCES, STATE LAM, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY EN\nRCNMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THISPERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORNEt3 - - OF .• APPLICANTS SIGNATURE � =.`COKITRACTOR INFID MMON TANK ID # I TANK SIZE I TANK CONTEN(S PRESENT.I. PAS_; DATE INS-ALLeD CONTRACTOR NAME Jar 7\, r eO 1 } S(�ncPtiONECONTRACTOR I ADDRESS 351 C er-Y-mPn_ �A L CA LIC# Y11Sb CLASS A Hwt INSURER i -t WORKER COMP# 1(0'7 I L i3 FIRE DISTRICT C. } fF d PERMIT it LABORATORYNAME CFI Tect, COUNTY Orx C PHONE# S(oL-1%Z-1760 SAMPLINGFIRM v Cleo v'ro, Mn 4..\ PHONE # Lk l- oo(. - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY CROINANCES, STATE LAM, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY EN\nRCNMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THISPERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORNEt3 - - OF .• APPLICANTS SIGNATURE � I Aj'u', iN> GPMAT'n_!% - TANK ID # I TANK SIZE I TANK CONTEN(S PRESENT.I. PAS_; DATE INS-ALLeD I APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY CROINANCES, STATE LAM, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY EN\nRCNMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THISPERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORNEt3 - - OF .• APPLICANTS SIGNATURE �