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� <br />!, A,3 5tl`4 9 <br />r B�i. <br />APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br />THIS PERMIT FOR PERMANENTrFEMPORARY 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 />FACILITY INFORMATION <br />EPA SITE #C7'1C-OIC,&3t'I13 PROJECT CONTACT -JOA - I7 I-- I PHONE# <br />FACILITYNAME AG OK -35 �L•C. PHONE#'- G7.'. -r <br />ADDREf. <br />SS G"SC% I ' n6 'v0. IY✓r.0 iTG yljQ J3-1 G <br />CROSS STREET (nf <br />OWNEROPERATOR GKRC- HoAaR G '1•.'LI:. IPHONE# <br />CONTRACTOR INFORMATION <br />TANK ID # <br />CONTRACTOR NAME ' ,L -�l't � - ) -"v--rig <br />. Inc • <br />PHONE # (20+) e 1��- C? 5 , <br />CONTRACTOR ADDRESi 5 pr Aar WAV <br />ItA %4 CA LIC # <br />CLASS <br />INSURER `�-1C7, <br />WORKER COMP# %� . ' <br />SCC 13 >' C5 <br />FIRE DISTRICT JOQlin CCL%i <br />PERMIT# <br />39- <br />LABORATORY NAME KjjT <br />COUNTY <br />PHONE # 3G Z i 2' yC <br />SAMPLING FIRM lio.Se1C, P}co r-wr�Secv�c:.c� nC, <br />PHONE # '4-&011 <br />fir i 60,i nA X L )64- 1415-- gt: Q l <br />TANK INFORMATION <br />TANK ID # <br />TANK SIZE TANK CONTENTS PRESENT & PAST DATE INSTALLED <br />39- <br />L�kntWfI <br />FKidLr. k sW�l <br />39- � %,tl k <br />C C , uAkii Fwe I h knii <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 ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S 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 BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING <br />SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL <br />EMPLOY PERSONS SUBJECT TO MRKER'S COMPENSATION LAWS OF CALIFORNIA." <br />APPLICANT'S SIGNATURE <br />TITLE l VIAfdi!` 0f- DATE 200. <br />❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br />(SEE CONDITIONS BELOW ANDIOR ON ATTACHMENT) <br />PLAN REVIEWER'S NAME DATE -- <br />ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. <br />CONDITIONS: <br />EH 23 046 (Revised 12/31/07) <br />