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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR STORAGE TANK(S) XPIRES 90 DAYS PROM THE ARARY PPROVAL DATE. 00 NOT WRITE URE OR ABANDONMENT IN CHAZARDOUSE OF UNDERGROUND N ANY SHADED AREAS. INDIICATE PERMITATYPES REMOVAL CITEMPORARYCLOSURE ❑ CLOSURE-IN PLACE FACILITY INFORMATION EPA SITE#C-A' - 2 PROJECT CONTACT xt7 -T PHONE# FACILITY NAME a PHONE# Z -`l ADDRESS 2 CROSS STREET ( L-Aj OWNEROPERATOR AG1� �� I7 E�0-- PHONE# cj2�"E'221i- /I> CONTRACTOR INFORMATION CONTRACTOR NAME PHONE# CONTRACTOR ADDRESS CA LIC# CLASS INSURER WORKER COMP# FIRE DISTRICT PERMIT# LABORATORY NAME COUNTY 4GIa4iA PHONE# GIZf S SAMPLING FIRM PHONE # , TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39- Lc 4✓ o oozy `1 39- 39- 39- 39- APPLICANT 9-3939- 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: Y CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 WORKERS COMPENSATION LAWS OF CALIFORNIA.' APPLICANT'S SIGNATURE TITLE DATE ❑ APPROVED ❑ APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) PLAN REVIEWER'S NAME DATE ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO END FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: i EH 23 045(REVISED 08113199) Page 3