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VOW D <br /> sRSIf ��rvv17Cony <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGROUND STORAGE TANK CLOSURE PERMIT <br /> APPLICATION FOR PERMANENT/TEMPORARY CLOSURE OR ABANDONMENT IN PLACE OF UNDERGROUND HAZARDOUS SUBSTANCE STORAGE TANK <br /> THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE _ CLOSURE IN PLACE <br /> EPA SITE / PROJECT CONTACT i TELEPHONE / <br /> FFACILITY NAME PHONE Y <br /> A Farmin ton Fire De t. - <br /> C ADDRESS25474 E. Hwy 4, Farmington, CA 95230 <br /> 1 <br /> L CROSS STREET <br /> 1 <br /> T OWNER/OPERATOR PHONE N <br /> Y Don Briggs, Fire Chief (209) 886-5328 <br /> C CONTRACTOR NAME Pa dirt Excavatin2 Co. Inc <br /> PHONE N (209) 599-2347 <br /> 0 <br /> N CONTRACTOR ADDRESS 269 Oregon St R' CA LIC N CLASS <br /> T <br /> R INSURER S. N. Potter IRs. Agency, Stockton, CA WORK.CCMP.N 10 WC20011206E <br /> A PERMIT N <br /> T <br /> C FIRE DISTRICT Farmington Fire District <br /> 0 LABORATORY NAMESherwood Labora Or PHONE N (209 667-5259 <br /> R <br /> SAMPLING FIRM PHONE N 209 847-8757 <br /> nnnnunnnufilimir ivi <br /> TANK ID N TANK SIZE CHEMICALS STORED CURRENTLY/PREVIOUSLY DATE UST INSTALLED <br /> 39gaso i.ne <br /> T 39- <br /> A 39- <br /> N 39- diesel <br /> K 39- <br /> 39- <br /> uii m i RnrnrrmnrmtR <br /> P <br /> L APPROVED APPROVED WITH CONDITION(S) DISAPPROVED <br /> A TACHMENT WITH CONDITIONS) <br /> N PLAN REVIEWERS NAMEDATE - <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT 70 WORKER'S <br /> COMPENSATION LAWS OF CALIFORNIA.• <br /> APPLICANT'S SIGNATURE: C'ZC- (� TITLE �� C.� DATE -I <br /> EH 23 046 (Revised 7/10/92) Page 3 <br />