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JMt� JML.IU114 VVUIV 1 1 rUDLIL, nr_M. 1 JCtCV IVCD <br /> �- ENVIRONMENTAL HEALTH DIVv6ION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENTITEMPORARY 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 ❑ TEMPORARY CLOSURE ❑ CLOSURE-IN PLACE <br /> FACILITY INFORMATION <br /> EPASITE#Ift9b93J37Y739 PROJECT CONTACT L Tf I r\ PHONE# 3S', 25 <br /> FACILITY NAME FIN 41r �-^ PHONE#(�O� 9 " 9 <br /> ADDRESS / $ / I C5 J o% � <br /> CROSS STREET <br /> OWNER OPERATOR r n PHONE# <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAM N UC PHONE# SI&-1510 <br /> CONTRACTOR ADDRESS 4 o5 QI 934135 I CA LIC#663)&9 ) CLASSA L C5'7' <br /> INSURER WORKERCOMP# (p 5'O,�- ' <br /> FIRE DISTRICT p Qy PERMIT# <br /> LABORATORY NAME COUNTY ULACI I PHONE# 67' oZ S <br /> SAMPLINGFIRM I PHONE # <br /> TANK INFORMATION <br /> TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED <br /> 39- COO <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: '1 <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER A$ <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 OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA.' <br /> APPLICANTS SIGNATURE TITLE DATE <br /> ❑ APPROVED VAPPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BE W AND/OR ON ATTACHMENT) <br /> PLAN REVIEWER'S NAM DATE�I,.J»`p s <br /> ANY DEVIATIONS FROM THIS APPLICATION MUST BE ED TO R APPROVAL PRIOR TO COMMENCINNGG WWOOR``K. <br /> CONDITIONS: <br /> _��c d�CCF��ae>e� cc»�acc�o� OF A4P(toJ4� <br /> EH 23 046(REVISED 08/13199) Page 3 - _ <br />