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;925 S5t 7888 # 2/ 6 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> ENT IN NCES <br /> STORAGETANKPLAE OF UNDERGROUND HAZARDOUS IS M05)EXPIRES 90 DAYS FROM THE APPROVAL DATE. 00 OT WRITE CN ANY SHADE AREAS- INDICATE PERMITATYPE: <br /> XREMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE;; Z PROJECT CONTACT C'T t PHO Et _XCI LfoA�` 1ol0 <br /> PHON # - <br /> FACILITY NAME t <br /> I ADDRESS ` <br /> CROSS STREET A'[� <br /> PHONE# <br /> pW NER OPERATOR <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME - PHONE#y <br /> CONTRACTOR ADDRESS OA 1 U CALIC# '�C/ 3 CLAS <br /> INSURERCALIF-- WORKER Comp;; 2 4 I <br /> FIRE DISTRICT PERMff# <br /> LABORATORY NAME COUNTY �CILU PNDNE# Ztl <br /> 5 6 <br /> SAMPLINGFIRM .t PHONE It <br /> TANK INFORMATION <br /> TANK 10 P TANK SIZE TANK CONTENTS jPR9SENT& PASTI DATE INSTALLED <br /> 39- 2oK}e b oOD &0". 1 'l w <br /> 39 5 LC L. <br /> 39- <br /> 39. <br /> � 39- <br /> I 39" <br /> f APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.Fm ORAL LAWS,AND RULES AND <br /> REGULATIONS OF SAN JOAOUW COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: T <br /> CERTIFYTRLT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SFA"NOT EMPLOYANY 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 /> THEFOLLOWING: -1 CERTIFYTHAT IN THE PEF3FORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OFC NIA' yn <br /> APPLICANT'S SIGNATURE TITLE 1 r O E DATE ' 0� <br /> © APPROVED ROVED WITH CONDITIONS) ❑ DISAPPROVED <br /> (S E CONDrt IS BELOW ANWOR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM ' v` DATE <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUE REO TO END FOR APPROVAL PRIOR TO COMMENCING WORK <br /> CONDITIONS: <br /> EH 23 046(REVISED 00/13@S) page ' <br />