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an g M I)1) ? Ij ia 'I) ` I APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S) EXPIRES 180 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION }1C. EPA SITE # C!C'/1r-3 42,5 PROJECT CONTACTjC L n 1 ' PHONE# ZCF C ` `3Cl eil FACILITY NAME FRAC.. cKA-�> )r B.C., NE#° ADDRESS G'�C t �flC�f 10� rGCC Ii GFylla. J (I+' CROSS STREET (- F1VC " LiI C OWNEROPERATOR GV4AC- Lt CC IPHONE# CONTRACTOR INFORMATION CONTRACTOR NAME 'I 1L old Chi i'' toic PHONE# C'O C?� CONTRACTOR ADDRESS qJ ' .KS 0 AAE.r '> Y �! CSA r63C CA LIC# -. L I I CLASS ti ' INSURER (_fund WORKER COMP# t ` C`G C 13)�✓� FIRE DISTRICT SCO. +fn�i rl Coi.'Jnt PERMIT# 39- LABORATORY NAME . fy A 1 COUNTY PHONE # J . zR SAMPLING FIRM Kolotc_1 C�'!"01cu.,�Ser•Y_c.c ,'Inc- I PHONE#: tug- "�5. 39- APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO �V7gRK(�EER'S COMP f�GISATION S OF CALIFORNIA." //y' ,,,] 1 APPLICANT'S SIGNATURE `61k1A/y1� ``��J� TITLEILIl1L �P�OB DATE�II'1�` ❑ APPROVEDAPPROVED WITH CONDITION(S) ❑ DISAPPROVED EE CO ITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME Alz R I DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BEUS ED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. C DITIONS: EH 23 046 (Revised 12/31/07) TANK INFORMATION TANK ID # TANK SIZE TAUKCQNTFNT RECENT g_ PASTJ DATE INSTALLED 39- C4h I10cc) u t F illG 3g - �' m F, t 0 , [ ' ' 39- 39- 39- 39 - APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, FEDERAL LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I 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 TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA:' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO �V7gRK(�EER'S COMP f�GISATION S OF CALIFORNIA." //y' ,,,] 1 APPLICANT'S SIGNATURE `61k1A/y1� ``��J� TITLEILIl1L �P�OB DATE�II'1�` ❑ APPROVEDAPPROVED WITH CONDITION(S) ❑ DISAPPROVED EE CO ITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME Alz R I DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BEUS ED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. C DITIONS: EH 23 046 (Revised 12/31/07) EH 23 046 (Revised 12/31/07)