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SAN-.JAQUIN COUNTY PUBLIC HEALT,. SERVICES ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT THIS PERMIT FOR PERMANENTMEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCES STORAGE TANK(S)EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE: REMOVAL ❑ TEMPORARY CLOSURE ❑ CLOSURE IN PLACE FACILITY INFORMATION EPA SITE# PROJECT CONTACT Pill I f PHONE# FACILITY NAME PHONE ADDRESS CROSSSTREET ;6 i OWNER OPERATOR PHONE# CONTRACTOR INFORMATION CONTRACTOR NAME I fc T III(<OVrA Se�/LV1t-F-S LAIC. PHONE# -97 CONTRACTOR ADDRESS CA LIC# CLASS INSURER ' RKER COMP# - FIRE DISTRICT Gr imy PERMIT# LABORATORY NAME ...... COUNTY; --� SAMPLING FIRM PHONE R TANK INFORMATION TANK ID# TANK SIZE TANK CONTENTS PRESENT 8 PAST) DATE INSTALLED 39- 1Aj 39- 39- 39- 139- 1139- 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 UCENSED 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 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 WORKER'S COMPENSATION LAWS OF CALIFORNIA." ,(J // APPLICANTS SIGNATURE TITLE /-PC S lyel-� DATE O:APPROVED 15 APPROVED WITH CONDITION(S) ❑ DISAPPROVED n (SEE CONDITIONS BELOW AND/OR ON ATTACHMENT) /,, PLAN-REVIEWER'SNAME�,��/I/U \ ( <,� DATE/.16/0/-� ANY DEVIATIONS FROM.THIS APPLICATION MUST BE SUBMITTED TO EHD FOR APPROVAL PRIOR TO COMMENCING WORK. CONDITIONS: EH 23 046(REVISED 1011 9M) Page 3