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SAN.JAQUIN COUNTY PUBLIC HEALSERVICES ENVIRONMENTAL HEALTH DIVISION 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 g0 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: ❑ REMOVAL ❑ TEMPORARY CLOSURE ,SCI C ��RE'I�PSLACE FACILITY INFORMATION !� /- EPA SITE# PROJECT CONTACT ;L-C PHONE# PHONE# :Z.r. 00 FACILITY NAME T . ADDRESS "IL <� CROSS STREET PHONE# OWNER OPERATOR K CONTRACTOR INFORMATION PHONE# B CONTRACTOR NAME CA LIC# &fVZZ7 I CLASS A Z CONTRACTOR ADDRE S g• KER COMP# I INSURER PERMIT# FIRE DISTRICT �y-�,�` COUNTY P ONE# LABORATORY NAME /ter e[ 1�' L�� PHONE # SAMPLING FIRM L^r 4F!- TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT& PAST DATE INSTALLED 39- (o ^^ 3 DOD M U 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 PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENTS 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 RT WORKERS COMPENSATION LAW HE WORKRFOR WHICH THIS PERMIT IS ISSUEDHIRING OR U SHALLEMPLOY PERSONS SUBJECT TO CTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE RF WORKER'S COMPENSATION LAWS OF ��jj,��i �r �/� l APPLICANTS SIGNATUR ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) Q /i / y, DATE IN I I O K. I PLAN REVIEWER'S NAME T F-a ANY DEVIATIONS FROM THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. n p CONDITIONS: 12 EH 23 046 RE ED 08/13/9 Page 3