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SAG,..,Dy-.4UIN COUNTY PUBLIC HEAL �RVICES <br />ENVIRONMENTAL HEALTH DI I <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTfTEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br />STORAGE TANK(S) EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br />,REMOVAL <br />❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br />u <br />FACILITY INFORMATION <br />EPA SITE# <br />39 PROJECTCONTACT PHONE# /V NG <br />FACILITY NAME <br />• - PHONE # <br />ADDRESS <br />6t 2� CA LIC # CLASS - L <br />CROSS STREET <br />'rh G� <br />3I- LOO <br />OWNER OPERATOR <br />i r PHONE# <br />u <br />_ TANK INFORMATION <br />CONTRACTOR INFORMATION <br />TANK SIZE TANK CONTENTS PRESENT & PAST <br />it PHONE# zn - 37- <br />CONTRACTOR NAME <br />39- <br />39- <br />39- <br />39- <br />39 - <br />6t 2� CA LIC # CLASS - L <br />CONTRACTOR ADDRESS <br />W KER COMP#' �O <br />INSURER <br />FIRE DISTRICT � <br />PERMIT # li <br />COUNTY .ro PHONE ZD 2-O 1670 <br />LABORATORY NAME - <br />SAMPLING FIRM <br />PHONE # 20 - O <br />_ TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS PRESENT & PAST <br />DATE INSTALLED <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 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 CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE FTHE WORKFOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNI 7�J <br />APPLICANT'S SIGNATSU <br />ITLE �I L�_/ r DATE 111C4/ <br />F PROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />/ // �--/ �//^^�1�C_ L// (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) <br />[PLANIEWER'S NAME r DATE <br />Iq <br />DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />6AQ Corr�C-t- (�]LYtr -60 'rW i' 4" o 4, r,n.p on .-.rnv� p <br />�JA n1.� 12111arol�?rd I �I` - <br />r <br />P 3 <br />EH 23 046 (REVISED 08/13/99) age <br />