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S8..,JJOAQUIN COUNTY PUBLIC HEAL- SERVICES <br /> ENVIRONMENTAL HEALTH DIVI'dfON <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTREMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANKS)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE# PROJECT CONTACT PHONE# <br /> FACILITY NAME PHONE# <br /> ADDRESS <br /> CROSS STREET <br /> OWNER OPERATOR PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME � PHONE# <br /> CONTRACTOR ADDRESS CA LIC# CLASS a� <br /> INSURER T WORKER COM L'I• i(' <br /> FIRE DISTRICT . PERMIT# <br /> LABORATORY NAMEye <br /> COUNTY PHONE <br /> q SAMPLING FIRM PHONE # <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE TANK CONTENTS IPRESENT& PAST DATE INSTALLED <br /> 39- a <br /> 39ot- <br /> 39- <br /> 39- p <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 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 IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF ALIFORNIA.' M- /f <br /> APPLICANT'S SIGNATURE TLE !/ �� "�� //C9�_ DATE ` !!7 <br /> ❑ APPROVED IYAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE DNDITID ELOW AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAME I DATE <br /> -� <br /> ANY DEVIATIONS FROM THIS APPLICATION MUSST BE SUBM D TO EHD FOR APPROVAL PRIOR COMMENC NG WORK. <br /> (OITIOMS� C�o�id7�-t-i <br /> EH 23 046(REVISED 08/13199) Page 3 <br />