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Jul, 22. 2013 9:33AMNo. 3182 P. 2 <br /> • • <br /> ENVIRONMENTAL HEALTH DEPARTMENT ��' <br /> SAN JOAQUIN COUNTY <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK(S)EXPIRES 180 DAYS FROM THE APPROVAL DATE, DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> r IF Qf I�. .N � �T70)V , <br /> EPA SITE# (S Z. PROJECT CONTACT Lc•- • PHONE# rl6$=�.S� 717 <br /> FACILITY NAME 7- arm o&' / / / PHONE# <br /> ADDRESS Z 7 2.S~ CO 14 N ho v Cd,4Val. -J/p G/ ONE cc, r144 d <br /> CROSS STREET zY. Axdr- <br /> OWNER OPERATOR LuFt+ J 7-5-221,07iA PHONE# <br /> 1. .�. i :,v R I�{/.Xx,l ff�.. �'`6,� •S4 _..•�. S� .. _ .l:^iwJl{ A':.,,.. <br /> CONTRACTORNAME G7"J'• rYt PHONE# 6d '69 <br /> CONTRACTOR AODRE8S,30 p OG LIC# J06J40- CLASS J.T'G"V N42 <br /> INSURER , d r' C - WORKER COMP# OO 77-FIREOISTRICT QiJr Ya/ 2 k h e� PERMIT# O (1`-Z6 -.1 L•- -W Z- <br /> LABORATORYNAMEi T LT' .2n c. COUNTY y PHONE# �� 2-17q4'00 <br /> SAMPLING FIRM n PHONE# <br /> TANK INFORMATION <br /> TANKID# T KSIZE TANKCONTENTS PRESENT AND PAST T I-7DASTALLED <br /> 39-o�Z1/0730 7 6nn ( so�i�c / « 0 <br /> 39-oDo237o7J6-yot 4 c On a 7-17 c/ <br /> 39- <br /> 39- <br /> 39 <br /> 39- <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,FEDERAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE <br /> FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH <br /> A MANNER AS TO OR SUBOONTRACTING <br /> SIGNATURE CERTIFIES THE EFOLBLOWING:O*1 CERTIFY THATORKER'SMIN THETION P RFO MANCELAWS OFCOf THE WORK FOR VM CH TH SIRING PERMIT IS ISSUED, II SHALL <br /> EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA" <br /> APPLICANTS SIGNATURE TITLE Jr'r'.ln � �4,`r.,.�P�✓�+l1TidATP ^7 � <br /> q APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVE <br /> (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br /> Lry <br /> PAYE <br /> 'S NAME <br /> ,IEVIEWER <br /> sI ,'N1Y DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK <br /> qv. , <br /> CONDITIONS " <br /> 4 <br /> Ell 23 046 (Revised 10130/12) 3 <br />