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SAN JOAQUII�OUNTY PUBLIC HEALTH SERVO dS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> THIS PERMIT FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES <br /> STORAGE TANK E.)EXPIRES 90 DAYS FROM THE APPROVAL DATDO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: <br /> ® REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE <br /> FACILITY INFORMATION <br /> EPA SITE Z PROJECTCC.-.TACT F to gZC PHCNE# LCR"4K <br /> FACILITY NAMEL PHONE# <br /> ADDRESS 20o c!t rSZ3t <br /> CROSSSTREET <br /> O- PERATOR PHONE#20q- <br /> CONTRACTOR INFORMATION <br /> CONTRACTOR NAME 62 Ga. PHONE#LOq S/- <br /> CONTRACTOR ADDRESSp I.E.K, CA LIC# /O CLASSC6/ o/ Z <br /> INSURE M1 WORKER COM Q t(w <br /> FIRE DISTRICT PERMIT# <br /> LABORATORY NAME tA, PI_AU{TIeRI COUNTY At&A4ea&l PHONE#67&-129V- &T-D <br /> SAMPLING FIRM PHONE 4 ZOR - 17 OO(p <br /> TANK INFORMATION <br /> TANK 10# TANK SIZE i TANK CONTENTS(PRESENT& PAST) DATE INSTALLED <br /> 39-1S Z K <br /> 39- ) -pZ _ <br /> 39- _ z- Ll tA Lyp'nao <br /> 39- <br /> 39- <br /> 39- I <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE`•'ATH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.FEDERAL LAWS.AND RULES AND <br /> REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEA..'.-. SERVICES. OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING: 'i <br /> CERTIFY THAT IN THE PERFORMANCE OF THE WORK F7: NHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS <br /> TO BECOME SUBJECT TO WORKER'S COMPENSATION OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PER OR C&.]F THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO <br /> WORKER'S COMPENSATION W39 L <br /> APPLICANTS SIGNATURE TITLE LATE g� <br /> ❑ APPROVED APPROVED WITH CONDITION(S) ❑ DISAPPROVED <br /> (SEE CONDITIONS BELOWAND/OR 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 /> LA AA llkw <br /> EH 23 046(REVISED 10/19/98) Page 3 <br />